Thank you for your interest in Dana Group Associates!
The following documents are included:
Please complete EACH of the items. If the items do not pertain to you, please
answer “N/A.,” “none,” or put a dash through the answer box.
*Guardian Authorization (REQUIRED)*
All persons who have custodial rights of the child MUST
complete and sign the parental authorization form.
Divorced or separated parents:
If both parents do not have full custody, both parents will need to provide two parental authorization
forms as well as a copy of the custody outline from the divorce/separation agreement, We only ask that
the parent submit the page(s) of the document that outline the custody rights of each parent as well as the signature page —not the entire divorce decree.
Foster parents or children in the Department of Children & Families (DCF) custody:
If the child is in custody of DCF, DGA requires an ROI signed by the DCF caseworker in order to provide treatment for the child.
Release of Information (ROI)
An ROI authorizes DGA to request, obtain and/or exchange documentation
with outside facilities and individuals other than yourself. ***When requesting medical records, please note that facilities legally have 21 days to process the request. For some cases, DGA cannot schedule an appointment until we receive the requested records. Once we receive and review the requested records, we will contact you with next steps. ***
PLEASE NOTE THAT MANY FACILITIES ACCEPT ONLY THEIR SPECIFIC RELEASE OF INFORMATION FORM. PLEASE, CHECK THE FACILITY’S WEBSITE, OR CONTACT THEIR MEDICAL RECORDS DEPARTMENT TO ENSURE THAT YOU ARE COMPLETING THE CORRECT RELEASE FORM.
Reasons to complete a Release of Information (ROI):
If you have had any inpatient hospitalization for psychiatric reasons, within the past 12 months, please complete one ROI for EACH facility. If you have been hospitalized within the past 12 months, our medical team will review the hospitalization records prior to scheduling an appointment. If you believe that it would be beneficial to your treatment with DGA, you may complete an ROI for a previous or current provider (e.g., PCP, therapist, prescriber, school, etc If you want to authorize a family member or a friend to be contacted about your treatment/services, please complete an ROI form for EACH person.
Once completed, email the forms to our secure email (firstname.lastname@example.org
You may fax completed forms to our secure fax (339-788-9116)If you fax any documents, please follow up with the intakes department by email or by phone to confirm our receipt of the documents.
If you have any questions, please contact our intakes department by phone or by email.