Adult ROI - Authorization for Release of Information

Authorization for Release of Information
I name* , relationship to client*, authorize the following provider(s) to use and/or disclose protected health information regarding: Client' s Legal First Name* Client's Legal Last Name* Client's Date of Birth*
Please fill in information for all providers/clinics you would like to authorize an exchange of information.
Talk Play Learn Speech Therapy 6523 SE King Rd Milwaukie, OR 97222 Phone: (503) 852-1375 Fax: (503) 893-3063 may*

send/disclose protected health/educational information (PHI) andreceive/use protected health/educational information (PHI)

with the following entities*

	name of individual/clinic/school district	mailing address	phone #	fax #
Provider 1
Provider 2
Provider 3
Provider 4

The information that will be used or shared includes (check all that apply):*

medical recordstreatment records (progress notes, daily records)speech, language, voice, or swallowing test resultsIEP/IFSP documentOther

By initialing the spaces below, I authorize the use/disclosure of the following information:

	initials
Alcohol/drug treatment
HIV/AIDS-related information
Mental Health Information
Genetic Testing Information

This information is being used or shared for the purpose of:*

Evaluation/AssessmentCoordinating treatment effortsOther
This consent will automatically expire in one (1) year after the date of my signature as it appears below, or on the following earlier date, condition, or event
I understand that:
- I do not have to sign this authorization. I will still be able to get treatment here even if I do not sign it.
- I am allowed to see or copy the health information that will be used or shared, including this form.
- I may revoke this authorization at any time by notifying Talk Play Learn Therapy in writing. Any information that was used or shared before I revoked the authorization cannot be returned.
- Federal privacy rules for protected health information apply only to health plans, health care clearninghouses or health care providers. If I authorize disclosure of medical information to other agencies or individuals, then the disclosed information may no longer be protected by general privacy regulations.
Signature*

Clear
Please enter the email where you would like to receive a copy of this form. Please note down the password for your records: Your1f@rm
example@example.com
Should be Empty: