Authorization for Release of Information (ROI)

Authorization for Release of Information

Authorize verbal and written communication between your providers for coordination of care and continuity of treatment.
I authorize my current mental health provider to verbally and/or in writing disclose and exchange confidential information with the provider listed below. This authorization is intended to facilitate coordination of care and continuity of treatment. I understand that only the information specified in this authorization may be shared.
Client Full Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Client Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Client Email Address*
example@example.com
FaithWorks Therapy-Shanae Farquharson, LMFT
sfarquharson@faithworkstherapy.com
Releasing Provider, Person Name or Self*
Practice / Agency/ Relationship Name *
Type 'Self' for info going directly to you
Releasing Provider/ Person Phone Number*
Type your number if info is sent to youFormat: (000) 000-0000.
Releasing Provider/Person Email Address*
Type your email if you would like info released to you
Verbal communication (phone or in-person)Written communication (email, letters)Electronic records exchange (secure platforms)
This authorization allows two-way communication between the providers listed above.
Intake informationDiagnosis & Treatment goalsTreatment Summary Letter RequestCoordination of Care/Consult with another Health providerTalk with Partner/Family memberOther (please specify)
I understand that certain information related to substance use treatment, HIV/AIDS status, and other specially protected health information may be subject to additional protections under federal and state law and may not be disclosed without specific authorization.
I understand and agree
Expiration of Authorization*
If you selected 'On a specific date,' please specify the date:

MonthDayYear
Date
I understand that I may revoke this authorization at any time by providing written notice. Revocation will not apply to information already shared based on this authorization.
Client Signature*
Date Signed*

MonthDayYear
Date
DateTime
Should be Empty: