Release of Information (ROI) Form
Use this secure form to authorize We Care Daily Clinics to exchange health information with another provider or organization to support your care, treatment coordination, or transfer of services.
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email
example@example.com
Authorization to Exchange Health Information
I authorize:
Referral Agency / Facility Name
*
Agency Contact Name
Facility Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Facility Email
*
example@example.com
Facility Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Facility Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
To exchange health information with:
We Care Daily Clinics, LLC, all locations in Washington, including but not limited to [We Care Daily Clinics, 3320 Auburn Way N, Auburn WA 98002, 253-999-5750, 253-999-5740]
Purpose of Disclosure
Continuity of Care
Transfer
Communication with Care Team
Billing
Other
Information Requested / Authorized to Exchange
We request that the following records be sent to We Care Daily Clinics:
OUD Treatment Summary (including authorizations below)
Hospital H&P and Discharge Summary
Medication List
Immunization History
Problem List
Last Three Progress Notes
Test Results
None; establishing two-way release of information
Ongoing Authorized Information Exchange
Specify the health information you authorize to be exchanged today and in the future until expiration date below:
Initial Screening
Diagnoses and Problem List
Biopsychosocial Assessment
Treatment Recommendations
Medical Records
Test Results
Recovery Plan and Progress
Treatment Recommendations and Referrals
Dosing History
Face Sheet and Copy of ID
Other
Sensitive Information
The following information will not be released unless specifically authorized below. By checking the box, I authorize release of that information:
Information pertaining to substance use disorder diagnosis or treatment (42 CFR Part 2 and RCW 70.02.260)
Information pertaining to mental health diagnosis or treatment (RCW 70.02.230 and RCW 70.02.240)
Information pertaining to the testing, diagnosis, or treatment of sexually transmitted diseases, including HIV/AIDS (RCW 70.02.220)
Information pertaining to reproductive health care and gender-affirming treatment (RCW 7.115 and RCW 70.02)
Expiration & Revocation
Unless otherwise revoked, this Authorization expires 12 months after the date of signing. I understand that I may revoke this authorization at any time by submitting a written request to We Care Daily Clinics, except to the extent that action has already been taken in reliance on it. This authorization is voluntary. My treatment, payment, enrollment, or eligibility for benefits will not be affected if I do not sign this form. Once information is disclosed under this authorization, it may be subject to re-disclosure and may no longer be protected by federal privacy regulations (45 CFR Parts 160 & 164). Records released under this authorization are protected under HIPAA and 42 CFR Part 2, which prohibit further disclosure without my written consent.
Format & Method of Exchange
Records may be sent by secure fax, encrypted email, or uploaded via secure portal.
Requested Format:
Written
Verbal
Signature
Name
*
First Name
Last Name
Signature (Patient / Parent / Guardian):
*
Date
*
-
Month
-
Day
Year
Time
*
Hour Minutes
AM
PM
AM/PM Option
Relationship to Patient (Parent, Guardian, Conservator, Patient Representative)
*
NOTICE
Submit
Should be Empty: