Counseling Assoicates Release of Information (ROI)

AUTHORIZATION FOR RELEASE OF PROTECTED INFORMATION

COUNSELING ASSOCIATES OF CENTRAL IOWA, PC

3737 WOODLAND AVE., SUITE 601

WEST DES MOINES, IA 50266

PHONE 515-255-2224/FAX 515-255-2228

Please complete this form in its entirety. Items not checked or blank spaces are assumed to be non-applicable or specifically not authorized for release. This release is invalid if it does not contain the patient's original signature and date signed or if it has expired as described below. A copy of this signed form will be provided to the patient as requested.

Patient

DOB

Counseling Associates OR Doctor/Place Releasing Information

Address

City

State

Zip

Phone

Fax

Counseling Associates OR Where Information Is To Be Sent

Address

City

State

Zip

Phone

Fax

Check here if both parties will be receiving and releasing information:

Yes

Information Requested:

Complete Records/DemographicsNotesOther

Purpose of Release:

Continuity of CareTransfer of CareOther

I understand that this will include information relating to :

X Substance Abuse (Alcohol/Drug)

X Mental Health (Includes Psychological Testing)

X HIV-Related Information (AIDS-Related Testing)

X Genetic Information

X I give my consent to fax and/or mail my records. I understand that Counseling Associates of Central Iowa, PC may receive compensation for disclosure of the information released pursuant to this authorization.

I give Counseling Associates of Central Iowa, PC or the named agency my permission to release only the information I have selected on this form to the individual(s) or agency(ies) I have named and only for the purpose I have checked. I understand that this release is valid up to the expiration date stated below, and I may refuse to sign this authorization or revoke this authorization at any time. Any revocation or refusal to sign this authorization will not affect my ability to obtain treatment, payment or my eligibility for benefits. The revocation will take effect on the day it is received in writing. As a patient, I have the right to access my treatment records. Copies of the records may be obtained with reasonable notice and payment for copying cost. I further understand that if the person or entity that receives the above specified information is not a health care provider, health plan, or health care clearinghouse covered by the federal privacy regulations or a business associate of these entities, the information described above may be redisclosed and no longer protected by the regulations.

Signature of Patient or Legal Representative

Date

If not the patient, printed name:

Relationship

Witness

Expiration Date Or One Year From Signature Date