RELEASE OF INFORMATION (ROI) AUTHORIZATION FORM
This Release of Information form allows Kno’Qoti Native Wellness, Inc. (KNWI) to share or request specific information to support services, care coordination, or related assistance. Please complete all sections of the form accurately and review your information before submitting. By signing this form electronically, you are providing your consent for the release of information as described. If you have questions or need assistance before completing this form, please contact KNWI for support.
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YOUR INFORMATION
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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PURPOSE OF THIS AUTHORIZATION
I authorize Kno'Qoti Native Wellness, Inc. (KNWI) to exchange information as needed to assist with my care, services, program enrollment, case management, coordination of care, and overall wellness support.
I authorize KNWI to receive, share, or discuss the following information (check all that apply):
*
Healthcare Records
Case management
Behavioral or mental health information
Program enrollment or participation details
Substance use treatment information (42 CFR Part 2 Protected)
Social Services or benefits information
Other
PARTIES AUTHORIZED TO EXCHANGE INFORMATION
1.
*
2.
3.
4.
5.
6.
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METHOD OF COMMUNICATION
Method of Communication
In person
Phone
Email
Text message
Fax
Written documents
Other
EXPIRATION OF THIS AUTHORIZATION
This authorization expires on:
*
One year from the date of signature
When services with KNWI end
On this date:
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MY RIGHTS
I understand I may refuse to sign this form.
I may cancel this authorization at any time by giving KNWI written notice.
Canceling this authorization does not apply to information already released.
KNWI will not condition service on signing this unless allowed by law.
Information shared may be subject to redisclosure by the receiving party unless protected by federal or state law.
CLIENT SIGNATURE
Client Signature
*
Date
-
Month
-
Day
Year
Date
Release of Information for a Minor
If you are completing this release for anyone under the age of 18, please complete the section below.
Parent/Guardian Signature (if applicable)
Relationship to Minor
Date
-
Month
-
Day
Year
Date
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Submit
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