Release of Information (ROI) Form

  • 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 Date of Birth*
     / /
    • 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:
    • Do you wish to list any additional individuals, agencies or organizations other than the ones listed above?*
    • Information to be Shared 
    • What information should be shared? Check all that apply:*
    • Submission 
    • Did an HWS team member assist you with completing this form?*
    • Should be Empty: