Brittany Release of Information (ROI) for Emergency Contact

Release of Information (ROI) for Emergency Contact
Client Name*

First NameLast Name
Release of Information (ROI)

Contact Type: Emergency Contact
Emergency Contact Name*

First NameLast Name
Relationship to Client (E.g. Spouse, Parent, Friend)*
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ROI Start Date (Today's Date) ** Release of Information (ROI) forms renewed automatically after one year, unless requested to be rescinded*

MonthDayYear
Date
Person Obtaining Information:

Brittany Biddle, LPC

12320 Route 30, Unit 11

North Huntindgon, PA 15642

contact@michaelstephensphd.com

(412) 877-8011 - Contact Phone

(412) 353-3543 - Fax Number
I authorize the aforementioned persons to use, disclose, and/or release or exchange the following Protected Health Information (PHI) for the purpose of:*

Continuity of CareAuthorization of Services (if under 14)Treatment / Discharge PlanningOn-Site Consultation / Collaboration & Provision of ServicesEmergency Contact InformationClinical Concerns or Worries (Safety Information)Family / Couples Therapy SessionsOther
By methods of exchange:*

VerbalCopiesWritten / Electronic CommunicationFaxSessions / Collaboration AppointmentsOther
The following information to be released and/or exchanged is:*

Evaluations conducted by the practiceCurrent or Most Current Treatment PlanAcademic / School RecordsClinical Summary of Records or ProgressSocial and Family HistoryPsychotherapy Notes & Treatment Plan ReviewsMedical History and/or Physical ExaminationsDischarge Summary / Discharge NoteTwo-Way ConversationsSchedule Information / Adherence to Treatment FrequencyParent / Family / Couples Therapy SessionsEmergency Information
I have the right to revoke this authorization, in writing, by sending written notification of my revocation to my provider, Brittany Biddle, LPC. It is company policy, however, to have at least one identified emergency contact — so in the event of revoking this release of information you are required to identify a new individual for your emergency contact. I understand that a revocation is not effective to the extent that this authorization has already been utilized and relied on for authorized disclosure of protected health information (PHI). I understand that after the point of disclosure the information may be re-disclosed and no longer subject to protection.

My signature is an indication that I have read and understood the contents of this agreement or had it explained to me. By signing this form, I understand that I have the right to select or inspect the individually identified health information to be disclosed. I have checked above the information that has been authorized for clinically appropriate instances.
Client Signature*

Clear
Date*

MonthDayYear
Date
Signature of Spouse / Parent / Caregiver (*** ONLY NEEDED FOR A CLIENT UNDER 14 OR FAMILY / COUPLES SESSIONS)

Clear
Date

MonthDayYear
Date
Signature of Spouse / Parent / Caregiver (*** ONLY NEEDED FOR A CLIENT UNDER 14 OR FAMILY / COUPLES SESSIONS)

Clear
Date

MonthDayYear
Date
Should be Empty: