Release of Information (ROI) for Miscellaneous Party

Release of Information (ROI) for Miscellaneous Party
Client Name*

First NameLast Name
Release of Information (ROI)

Contact Type: Miscellaneous Contact
Name of Insurance Company (ONLY SELECT IF THIS RELEASE IS FOR A SECONDARY INSURANCE)
Miscellaneous Contact Name

First NameLast Name
Relationship to Client
Contact Phone Number
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Contact Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ROI Start Date (Today's Date) ** Release of Information (ROI) forms are valid for one year from the date signed*

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Date
Person Obtaining Information:

Michael Stephens, PHD, LPC

Michael Stephens PhD LPC Counseling Services PC

12320 Route 30, Unit 11

North Huntindgon, PA 15642

contact@michaelstephensphd.com

(412) 877-8011 - Contact Phone

(412) 353-3543 - Fax Number
I authorize the aforementioned persons to use, disclose, and/or release or exchange the following Protected Health Information (PHI) for the purpose of:*

Continuity of CareAuthorization of ServicesTreatment PlanningTransition / Discharge PlanningOn-Site Consultation / Collaboration & Provision of ServicesEmergency Contact InformationClinical Concerns or WorriesFamily / Couples TherapyOther
By methods of exchange:*

VerbalCopiesWritten / ElectronicFaxSession / Consultation AppointmentsOther
The following information to be released and/or exchanged is:*

Evaluations conducted by the practiceCurrent or Most Current Treatment PlansAcademic School RecordsClinical Summary of RecordsSocial and Family HistoryPsychotherapy Notes & Treatment Plan ReviewsMedical History and/or Physical ExaminationsSharing of Treatment StatusDischarge Summary / Discharge NoteTwo-Way ConversationsSchedule Information / Adherence to Treatment FrequencyParent / Family / Couples Therapy SessionCollaboration SessionsOther
I have the right to revoke this authorization, in writing, by sending written notification of my revocation to my provider, Michael Stephens, PhD, LPC. I can also verbally revoke this authoriziation in therapy sessions with my provider. I understand that a revocation is not effective to the extent that this authorization has already been utilized and relied on for authorized disclosure of protected health information (PHI). I understand that after the point of disclosure the information may be re-disclosed and no longer subject to protection.

My signature is an indication that I have read and understood the contents of this agreement or had it explained to me. By signing this form, I understand that I have the right to select or inspect the individually identified health information to be disclosed. I have checked above the information that has been authorized for clinically appropriate instances.
Client Signature*

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Date*

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Date
Signature of Spouse / Parent / Caregiver (*** ONLY NEEDED FOR A CLIENT UNDER 14 OR FAMILY / COUPLES SESSIONS)

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Date

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Signature of Spouse / Parent / Caregiver (*** ONLY NEEDED FOR A CLIENT UNDER 14 OR FAMILY / COUPLES SESSIONS)

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