Release of Information

Release of Information (ROI)
Client / Youth Name:*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Obtain FromRelease ToVerbally Communicate With
You can enter upto 6 Agencies or Persons in each ROI.
Agency/Person to Release Information To & From:*
Agency/Person Phone Number:*
Please enter a valid phone number.
Agency/Person to Release Information To & From:
Agency/Person Phone Number:
Please enter a valid phone number.
Agency/Person to Release Information To & From:
Agency/Person Phone Number:
Please enter a valid phone number.
Agency/Person to Release Information To & From:
Agency/Person Phone Number:
Please enter a valid phone number.
Agency/Person to Release Information To & From:
Agency/Person Phone Number:
Please enter a valid phone number.
Agency/Person to Release Information To & From:
Agency/Person Phone Number:
Please enter a valid phone number.
Assessments/EvaluationsDischarge SummaryEducation records (IEP, 504 Plan, Testing, etc.)Medical RecordsProgress Reports/NotesTreatment PlansOther
Beginning Date (Put Today's Date):*

MonthDayYear
Date
Expiration Date (Authorization can last up to one year):*

MonthDayYear
Date
I understand that my records are protected under state and federal law (Federal Privacy Regulations 45 CFR 160-164) and cannot be disclosed without my written consent except otherwise specified by the law. Further, I understand that if my records contain information regarding alcohol/drug abuse or HIV (AIDS) testing, they are protected under Federal Regulation 42 CFR Part 2, Confidentiality of Alcohol and Drug Abuse, & state law. I understand that I have access to my protected health information as outlined in the Notice of Privacy Practices. I am aware that I can refuse to sign this authorization.

I further understand that once my information is disclosed to the above authorized agency, Blue Kite Wellness, and its employees are not liable for the recipient’s actions with regard to my information. Once this information is sent, it may no longer be protected by the federal rule of privacy of records.

This authorization will have the duration of no longer than one year from the date upon which this form was signed. I understand that I may revoke my consent in writing at any time except to the extent action has been taken in reliance upon it. I understand I have the right to a copy of this signed authorization. I may obtain a copy of this authorization by contacting a Blue Kite Wellness representative, and the copy will be mailed or faxed to me promptly.
I have read carefully and understand the above and do herein expressly and voluntarily consent to the exchange of the above information to the agency/person identified above. I understand that under most circumstances Blue Kite Wellness may not condition treatment and/or payment on my signing of this authorization.
Name of Person Signing Form:*

First NameLast Name
Client {If 18 years or Older}Parent/Legal Guardian
Signature*
Today's Date:*

MonthDayYear
Date
Should be Empty:

Release of Information (ROI)