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
/
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:
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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
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
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
Coleman Health Services - All Locations in Ohio
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
Jefferson Co. Educational Services Center - OhioRISE CME - 2023 Sunset Blvd, Steubenville, OH 43952 - (740) 283-3347
Louisville City Schools - 407 East Main Street Louisville, OH 44641 - (330) 875-1666
Manor Avenue Elementary School - 230 E Manor Ave, Struthers, OH 44471 - (330) 750-1066
Ohio Guidestone - OhioRISE CME - All Locations in Ohio
Orange City Schools - 32000 Chagrin Blvd Pepper Pike, OH 44124 - (216) 831-8600
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
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
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 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
West Branch Local School District - 14277 S Main St. Beloit, OH 44609 - (330) 938-9324
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
GeneSight (Myriad Genetics) - 322 North 2200 West, Salt Lake City, UT 84116 - (800) 469-7423 - Fax: (801) 584-3615
Do you wish to list any additional individuals, agencies or organizations other than the ones listed above?
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Yes
No
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 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
Information of the Individual Completing this Release of Information
*
Sign Here Using Your Mouse
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Did an HWS team member assist you with completing this form?
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Yes
No
HWS Team Member Email Address
*
example@hwsbesthealth.com
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