Release of Information(ROI)

Authorization for Release of Information
I hereby grant permission to Fulfilled Care to disclose information from my medical and psychiatric records to the individuals and/or organizations listed below, and only under the specified conditions
Name(s) of Person(s) or Organization(s) to Receive Information:
Name of Person or Organization to Receive Information
Phone Number
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
Would you like to add an additional person or organization to receive your information?
Name of Person or Organization
Phone Number
Format: (000) 000-0000.
Name of Person or Organization
Phone Number
Format: (000) 000-0000.
Type of Information to be Disclosed:

By signing this consent form, I authorize the release of the following types of information from my medical records: initial assessments, diagnoses, psychiatric evaluations, substance abuse and alcohol information, behavioral assessments, medication details, therapy and counseling notes, blood work results and orders, progress notes, treatment concerns, bariatric concerns, appointment times and dates, and information related to financial discussions with office staff.

Duration of Consent:

This consent expires 90 days after discharge from treatment. This release will be valid until written notice to revoke this consent is provided to Fulfilled Care by patient/guardian and signed by both parties.

Revocation of Consent:

This consent can be withdrawn with written notice at any time, except in situations where actions have been taken based on the understanding that the consent will continue until its intended purpose is fulfilled. Any consent given will remain valid only for the duration necessary to accomplish its intended purpose.
Name of Patient
Patient Date of Birth

MonthDayYear
Patient/Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

Authorization for Release of Information

Name(s) of Person(s) or Organization(s) to Receive Information: