Release of Information (ROI)

Release of Information
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
By consenting to this release, I acknowledge that Heart and Solutions, LLC will send a copy of this ROI to the provider listed below. No additional information or records will be released without my verbal consent.
I authorize Heart and Solutions, LLC to release information to and obtain information from:
Agency / Professional / Individual (to decline, please write DECLINE)*
City*
Fax Number or Email*
This release will be effective for one year from the date signed unless specific dates are indicated here: From Date to Date .
Information checked in the section below may be released and obtained regarding all dates of service unless other wise specified here: From blanks to blank .
Presence & Progress in TreatmentMedical History and Medication RecordsPsych Testing results and infoSymptoms, assessments, and DxTreatment plan & outcomePsych History and EvaluationDemographicsScheduling & Appt RemindersBilling & Insurance
Substance Use and Treatment InformationHIV/AIDS InformationOther (Please specify)
Please Exclude the following information:
Continuity of CareLegal UseProgram ComplianceOther (Please specify)
I understand that my health information is protected under the federal regulations governing the Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. part 2, that re-disclosure is prohibited, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 45 C.F.R. parts 160 and 164, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. The information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer will be protected by the HIPAA Privacy Law.

This form has been fully explained and I certify that I understand its contents. I understand that Heart and Solutions, LLC may not condition treatment on obtaining this consent/authorization from me.
I Decline
Client / Parent / Legal Guardian / Authorized Representative Signature*

Clear
*Jotform acts as a witness signature for this document
Relationship / Role (if applicable
Date*

MonthDayYear
Date
Should be Empty: