ROI

Authorization for Release of Medical Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Please select one or both of the following options:*

I authorize StrongTower Behavioral Healthcare, LLC to release information to the following Provider/Facility/IndividualI authorize StrongTower Behavioral Healthcare, LLC to receive information from the following Provider/Facility/Individual
Name of Provider/Facility/Individual *
Address of Provider/Facility/Individual*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Provider/Facility/Individual*
Fax Number of Provider/Facility/Individual (enter "N/A" if not applicable)*
Type of records to be requested/released: (check one)*

All RecordsMental Health RecordsLab ReportsOther
Authorization valid until: (check one)*

This date onlyOne year from the date of this authorizationIndefinitelyOther
I understand that:
• My right to health care is not conditioned on this authorization.
• I may cancel this authorization at any time by submitting a written request to the address at the top of this form, except where a disclosure has already been made in reliance on my prior authorization.
• If the person or facility above receiving this information is not a health care or medical insurance provider covered by privacy regulations, the information stated above could be redisclosed.
• There may be a charge for requested records.
Signature*
Relationship to Patient:
Today's Date*

MonthDayYear
Date
Should be Empty:

Authorization for Release of Medical Information