Release of Information Form
By signing this form, I am authorizing the selected entities/individuals to disclose to and to share with HWS Best Health, LLC (1303 W. Maple St. Ste. 102 North Canton, OH 44720) the information I have specifically specified below:
Client's Name
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First Name
Last Name
Client's Date of Birth
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Month
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Day
Year
Date
Client's Social Security Number
Please provide when possible
Entities/Individuals That May Share My Information
Select the entity/organization(s) that HWS Best Health has your consent to send and receive confidential information with. Select all that apply:
4KidHelp (Dr. Tom Reynolds) - 4368 Dressler Rd. NW, Suite 103 Canton, OH 44718 - (330) 433-1300
Aetna OhioRISE - 400 West Campus Road New Albany, OH 43054 - (330) 711-0773
Akron Childrens Hospital - 214 W Bowery St, Akron, OH 44308 - (330) 543-1000
Akron Public Schools - 10 N. Main Street Akron, OH 44308 - (330) 761-1661
Alliance City Schools - 200 Glamorgan St Alliance, OH 44601 - (330 )821-2100
Alta Bvehavioral Healthcare - All Locations in Ohio - (330) 793-2487
As You Are - (866) 219-8595
Balanced Innovative Care, LLC - Dr. Ahuja and Dr. Speer
Barlow Adams Behavioral Health - 20220 Center Ridge Rd. Suite 170 Rocky River, OH 44116 - (440) 409-0307
Belmont Pines Hospital - 615 Churchill Hubbard Rd, Youngstown, OH 44505 - (800) 423-5666
Boardman City Schools - 7777 Glenwood Ave, Boardman, OH 44512 - (330) 758-7511
Brio Neurobehavioral Consultants - 3567 Reserve Commons Dr #125, Medina, OH 44256 - (330) 321-3408
Broadway Academy - 5004 Glazier Ave, Cleveland, OH 44127 - (216) 271-7747
Cadence Care Network - OhioRISE CME - 165 E Park Ave, Niles, OH 44446 - (330) 544-8005
Canton City Schools - 305 McKinley Ave NW Canton, OH 44702 - (330) 438-2800
Canton Local Schools - 600 Faircrest St SE Canton, OH 44707 - (330) 484-8019
Cherrie Turner Tower (Michaels Communities) - 700 McKinley Avenue NW Canton, OH 44703 - (330) 859-6532
Coleman Health Services - All Locations in Ohio - (330) 673-1347
CommQuest - All Offices in Ohio - (330) 455-0374
Cuyahoga County Board of Developmental Disabilities - 1275 Lakeside Ave E, Cleveland, OH 44114 - (216) 241-8230
Cuyahoga County Children and Family Services - 3955 Euclid Ave #2505, Cleveland, OH 44115 - (216) 431-4500
Cuyahoga County Court - 1 W Lakeside Ave #202, Cleveland, OH 44113 - (216) 443-7000
Cuyahoga Job and Family Services - 1641 Payne Ave, Cleveland, OH 44114 - (844) 640-6446
Cuyahoga Metropolitan Housing Authority - 8120 Kinsman Rd, Cleveland, OH 44104 - (216) 348-5000
Daily Behavioral Health - 14538 Grapeland Ave, Cleveland, OH 44111 - (216) 252-1399
GeneSight (Myriad Genetics) - 322 North 2200 West, Salt Lake City, UT 84116 - (800) 469-7423 - Fax: (801) 584-3615
Head Start - 1366 Market Avenue North Canton, OH 44714 - (330) 454-1676
Integrated Behavioral Health Services - OhioRISE CME - 23850 Commerce Park Rd, Beachwood, OH 44122 - (440) 753-6030
Integrative Neuropsychology (Dr. Joshua Magleby, MD) - 3250 W Market St #106, Fairlawn, OH 44333 - (330) 873-9516
Jefferson Co. Educational Services Center - OhioRISE CME - 2023 Sunset Blvd, Steubenville, OH 43952 - (740) 283-3347
Kent Psychological Associates - 190 Currie Hall Pkwy, Kent, OH 44240 - (330) 673-5812
KidsLink Neurobehavioral Center - 899 Frost Rd, Streetsboro, OH 44241 - (330) 963-8600
Lighthouse Family Center - 2416 Whipple Ave NW, Canton, OH 44708 - (330) 305-2753
Louisville City Schools - 407 East Main Street Louisville, OH 44641 - (330) 875-1666
Magnolia Wellness & Psychology - (678) 824-7733
Mahoning County Board of Developmental Disabilities - 4791 Woodridge Dr, Youngstown, OH 44515 - (330) 797-2825
Mahoning County Children Services - 222 W Federal St 4th floor, Youngstown, OH 44503 - (330) 941-8888
Mahoning County Court - 120 Market St, Youngstown, OH 44503 - (330) 740-2104
Mahoning County Job & Family Services Division - 345 Oak Hill Ave, Youngstown, OH 44502 - (330) 640-6446
Manor Avenue Elementary School - 230 E Manor Ave, Struthers, OH 44471 - (330) 750-1066
Marlington Local Schools - 10320 Moulin Ave Alliance, OH 44601 - (330) 823-7458
Massillon City Schools - 930 17th St NE Massillon, OH 44641 - (330) 830-3900
MetroHealth Medical Center - All Locations in Ohio - (216) 778-7800
Nicole Ranttila, Psy.D. - 25 Boardman-Canfield Rd. Suite K5 South, Boardman OH 44512 - (330) 550-4101
Oakwood Counseling Center, Inc. - 1704 North Rd SE # 2 #2, Warren, OH 44484 - (330) 856-4111
Ohio Guidestone - OhioRISE CME - All Locations in Ohio
Orange City Schools - 32000 Chagrin Blvd Pepper Pike, OH 44124 - (216) 831-8600
Pathways Caring for Children - 4895 Dressler Rd NW Suite A Canton, OH 44718 - (330) 493-0083
Perry Local School District - 4201 13th St SW Massillon, OH 44641 - (330) 477-8121
Plain Local Schools - 901 44th Street NW Canton, OH 44709 - (330) 492-3500
Poland Local School District - 3030 Dobbins Rd. Poland, OH 44514 - (330) 757-7000
Portage Collaborative Montessori - 1000 55th St NE, Canton, OH 44721 - (330) 966-1912
Portage Path Behavioral Health - 340 S. Broadway Street Akron, OH 44308 - (330) 253-3100
Positive Education Program - OhioRISE CME - 3100 Euclid Ave, Cleveland, OH 44115 - (216) 361-4400
Ravenwood Health - OhioRISE CME - 12557 Ravenwood Dr, Chardon, OH 44024 - (440) 285-3568
Reclaimed Divergence - 4790 Red Bank Expressway Suite 216 Cincinnati, Ohio 45227
Red Oak Behavioral Health - 611 W Market St, Akron, OH 44303 - (330) 996-4600
Refuge of Hope - 715 2nd St NE, Canton, OH 44704 - (330) 453-1785
Seibring Local Schools - 510 North 14th St Sebring, OH 44672 - (330) 938-6165
Shipley Pediatrics - 919 2nd St NE #1132, Canton, OH 44704 - (330) 453-3386
Stark County Board of Developmental Disabilities - 2950 Whipple Ave NW, Canton, OH 44708 - (330) 477-5200
Stark County Childrens Network - 213 Market Ave N #200, Canton, OH 44702 - (330) 451-1700
Stark County Court of Common Pleas - 115 Central Plaza N, Ste. 400 Canton, OH 44702 - (330) 451-7931
Stark County Family Court - 110 Central Plaza S # 670, Canton, OH 44702 - (330) 451-7415
Stark County Job and Family Services - 221 3rd St SE, Canton, OH 44702 - (330) 452-4661
Stark County Probate Court - 110 Central Plaza S Suite 501, Canton, OH 44702 - (330) 451-7755
Stark Metropolitan Housing - 400 Tuscarawas St E, Canton, OH 44702 - (330) 454-8051
STEAM Academy (Warrensville) - 4700 Richmond Rd, Warrensville Heights, OH 44128 - (216) 595-2866
Summit County Board of Developmental Disabilities - 2355 2nd St, Cuyahoga Falls, OH 44221 - (330) 634-8000
Summit County Children Services - 264 S. Arlington St. Akron, OH 44306 - (330) 379-9094
Summit County Common Pleas Court - 209 S High St, Akron, OH 44308 - (330) 643-2162
Summit County Domestic Relations Court - 205 S High St, Akron, OH 44308 - (330) 643-2365
Summit County Job and Family Services - 1180 S Main St #102, Akron, OH 44301 - (844) 640-6446
Summit County Metropolitan Housing Authority - 100 W Cedar St, Akron, OH 44307 - (330) 762-9631
Summit County Probate Court - 209 S High St, Akron, OH 44308 - (330) 643-2330
Summit Psychological Associates - All Locations in Ohio -
Tallmadge City Schools - 486 East Ave Tallmadge, OH 44278 - (330) 633-3291
The Behavioral Wellness Group - 8224 Mentor Ave #208, Mentor, OH 44060 - (440) 392-2222
The Center for Effective Living - Beachwood Office - 23360 Chagrin Blvd. #110 Beachwood, OH 44122 - (440) 333-4949
The Center for Effective Living - Westlake Office - 24500 Center Ridge Rd building 4 suite 250, Westlake, OH 44145 - (440) 333-4949
The Center for Renewed Minds - 3570 Executive Dr Suite 202, Uniontown, OH 44685 - (330) 826-1430
The Knapp Center for Childhood Development - 1051 Tiffany S Suite A, Poland, OH 44514 - (855) 629-6277
Thrive Counseling Services - 4680 Douglas Cir NW, Canton, OH 44718 - (330) 703-6578
Thrive Early Learning Center - 4670 Richmond Rd STE 200, Warrensville Heights, OH 44128 - (216) 217-4562
Total Education Solutions (Dr. Jessica Emick, PhD) - 3428 W Market St Fairlawn, OH - (330) 668-4041
Trumbull Co Job & Family Services - 280 N Park Ave #1, Warren, OH 44481 - (330) 675-2000
Trumbull County Board of Developmental Disabilities - 45 North Rd., Niles, OH 44446 - (330) 652-9800
Trumbull County Children Services - 2282 Reeves Rd NE, Warren, OH 44483 - (330) 372-2010
Trumbull County Court - 161 High St NW, Warren, OH 44481 - (330) 675-2557
Trumbull Metropolitan Housing Authority (TMHA) - 4076 Youngstown Rd SE, Warren, OH 44484 - (330) 369-1533
Tuslaw Local School District - 1835 Manchester Ave NW Massillon, OH 44647 - (330) 837-7813
Vista Psychological & Counseling Centre - 1201 S Main St #100, North Canton, OH 44720 - (330) 244-8782
West Branch Local School District - 14277 S Main St. Beloit, OH 44609 - (330) 938-9324
Western Reserve Psychological Associates, Inc. - 4833 Darrow Rd # 101, Stow, OH 44224 - (330) 650-5338
Wingspan Care Group - OhioRISE CME - 22001 Fairmount Blvd. Cleveland, OH 44118 - (216) 320-6800
Wright Preparatory Academy - 1500 Superior Ave NE, Canton, OH 44705 - (234) 207-5455
Youngstown Metropolitan Housing Authority - 131 W Boardman St, Youngstown, OH 44503 - (330) 744-2161
Youth Intensive Services - 238 S. Meridian Rd. Youngstown, OH 44509 - (330) 318-3436
Check here if you do not wish to authorize any of the organizations listed above.
None of the above
Do you wish to list any additional individuals, agencies or organizations other than the ones listed above?
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Additional Authorized Parties
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Information to be Shared
What information should be shared? Check all that apply:
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All record types in this list may be disclosed on behalf of the above named individual.
Identifying information: name, birth date, social security number, sex, race, address, email address and telephone number.
Mental Health Progress Names/Assessment/Psychosocial Assessment/Diagnostic Assessment/ Integrated Assessment
Psychiatric Evaluation/H&P/lnpatient Psychiatric Record.
Psychological Evaluations including Forensic/Court Psychological, Neuropsychological, School Psychological or others
Discharge reports and summaries
Progress Notes/Progress Reports
Diagnosis Lists
Medication Lists
General Medical: medical records (except for HIV, AIDS and drug and alcohol treatment records) disability, type of services being received and name of agency providing services to me or the individual named above.
Social History: social history, treatment/service history, psychological evaluations and other personal information regarding the individual named above or me.
School Information: grades, attendance records, Individualized Education Plan (IEP), Individualized Family Service Plan (IFSP), 'Individualized Service Plan (ISP), Multi-Factored Evaluation (MFE), (Children's) Ohio Eligibility Determination Instrument (COEDI/OEDI), transition plans and vocational assessments regarding me or the individual named above.
Financial Information necessary to establish eligibility for public assistance including but not limited to pay stubs, W2's and tax returns, and other financial information.
Submission
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example@example.com
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HWS Team Member Email Address
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example@hwsbesthealth.com
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