Release of Information (ROI)
Please indicate which type of Release of Information (ROI) you would like to complete. If you would like Northwest ADHD to release or obtain information involving multiple third parties, please submit a separate ROI for each clinic or third party.
Type of ROI you would like to complete today:
*
ROI to release or obtain information from external provider, clinic, or other third party
Verbal only ROI
Request to release records to self
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Authorization to Use and Disclose Protected Health Information
Instructions
This form is for use by individuals who have been scheduled for their initial appointment at Northwest ADHD Treatment Center, or individuals who are currently patients. Do not submit this form if you have not yet been scheduled for an initial appointment, as we do not retain completed forms for individuals who do not yet have established patient accounts. Northwest ADHD Treatment Center needs medical records from your primary medical care provider (doctor) to help complete the ADHD evaluation process. To ensure your evaluation is completed as quickly as possible, please be sure you complete this form for your primary medical provider, and complete it again as many times as needed for any current or recent mental health providers, psychologists who completed previous evaluations, friends or family members, or other individuals or entities you would like NW ADHD Treatment Center to communicate with. Please note, speaking with someone who knows you well is an essential part of the evaluation process, and a completed release of information is needed to talk to anyone about you without you also being present. You may also prefer a friend, family member, or loved one to be involved in your care. If you would like to limit access, such as to appointment scheduling, or billing information, you can specify exactly what you are allowing us to share under the "Information Which May Be Used/ Disclosed" section, by initialing next to "Other" and completing the "describe:" response area. Northwest ADHD Patients are entitled to access to their full records at any time. You may use this form at any time to request all or part of your health information on file to date. Your health information may also be available to you already through your portal account. Only parents or legal guardians may complete this form on behalf of another person.
Patient Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
NW ADHD Clinician Name(s)
This release is valid for all Northwest ADHD Treatment Center clinicians who may be involved in patient’s care.
With my signature below:
Multiple boxes may be checked
If you would like Northwest ADHD Treatment Center to BOTH obtain information and provide information to another party, select BOTH of the top two check boxes.
I authorize NW ADHD Treatment Center to REQUEST records and OBTAIN information FROM the party listed below
I authorize NW ADHD Treatment Center to SEND records and PROVIDE information TO the party listed below
Provider / Clinic / 3rd Party Information
Provider / Clinic / Other 3rd Party:
Relationship to Patient:
Medical Provider, Mental Health Provider, School, Spouse, etc.
Provider / Clinic / 3rd Party Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Provider / Clinic / 3rd Party Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Provider / Clinic / 3rd Party Fax Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Information which may be used/disclosed
**An initial is required to indicated consent and allow NW ADHD to request or disclose
Initial for Diagnostic/ Evaluation Records
Initial for Treatment Plan
Initial for Progress Notes
Initial for Medical Records
Initial for Other (please describe)
I understand that other laws about sharing of mental health, HIV/AIDS, genetic, and alcohol/drug treatment information may apply. I understand & agree that this information will be disclosed if I place my initials in the applicable space below:
Initial for Mental Health Information (includes evaluation, behavioral health, and psychiatric treatment related information)
Initial for Genetic Testing Information
Initial for HIV/AIDS Information
Initial for Drug/Alcohol Diagnosis, Treatment, or Referral
Final Consent
I understand that I am not required to sign this authorization. If I refuse to sign this, it will not prevent me from getting mental health treatment at Northwest ADHD Treatment Center. The only exception is if the services I am seeking are only for providing health information to someone else and this authorization is needed to make the disclosure. I may revoke this authorization in writing at any time. If I revoke this authorization, the information described may no longer be used or disclosed for the purposes described here. If Northwest ADHD Treatment Center has already used or disclosed the information, that cannot be undone. I understand that the information used or disclosed as a result of this authorization may be subject to re‐disclosure and no longer protected under federal law. However, I also understand that federal or state law may restrict re‐disclosure of HIV/AIDS, mental health information, genetic testing information, and drug/alcohol diagnosis, treatment or referral information. To revoke this authorization please send a written statement to the office manager at the address or fax number listed above and state that you are revoking this authorization. Unless revoked, this authorization expires 90 days after the completion of treatment. You can revoke this release by sending written notice to our office staff or your provider.
Patient Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Today's date
Expand to add a Patient Guardian/ Authorized Representative Signature
Parent / Guardian / Representative Signature
Parent / Guardian / Representative Name:
First Name
Last Name
Parent / Guardian / Representative Relationship to Patient
Parent, guardian, school, case worker, etc.
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Verbal Only Authorization to Use and Disclose Protected Health Information
PATIENTS: Please complete this form for anyone you authorize Northwest ADHD to communicate with verbal only access. **Northwest ADHD Patients are entitled to access to their full records at any time. You may request a Self Release ROI, or complete it at our website at any time to request all or part of your health information on file to date. Your health information may also be available to you already through your portal account.
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
NW ADHD Clinician Name(s):
This release is valid for all Northwest ADHD Treatment Center clinicians who may be involved in patient’s care.
With my signature below:
Verbal communication ONLY (no exchange of records)
Verbal communication ONLY (no exchange of records)
This consent is limited to the release of verbal information only. Release of the specified verbal information to any person not specified is prohibited. This authorization shall be valid until 90 days after case closure, unless consent is withdrawn in writing, or another date is specified.
Verbal Communication Authorized To/By:
Provider / Clinic / Other 3rd Party Name:
Relationship to Patient
Medical provider, mental health provider, school, spouse, etc.
Provider / Clinic / Other 3rd Party Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Provider / Clinic / Other 3rd Party Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Provider / Clinic / Other 3rd Party Fax Number:
Please enter a valid fax number.
Format: (000) 000-0000.
Information which may be used/disclosed
**An initial is required to indicate consent and allow NW ADHD to request or disclose verbally. I hereby authorize Northwest ADHD to engage in verbal communication or to leave a detailed message with the individual(s) or organization(s) identified above for the following purposes (initial all that apply):
Initial for schedule, cancel, reschedule, or obtain information about past, current and future appointments
Initial for all aspects of my care, treatment and payment, including insurance, benefits, and claims
Initial for all clinical care, including test results and visit documentation
Initial Other:
Please describe:
I understand that other laws about sharing of mental health, HIV/AIDS, genetic, and alcohol/drug treatment information may apply. I understand & agree that this information will be disclosed if I place my initials in the applicable space below:
Initial for mental health information
Initial for genetic testing information
Initial for HIV/AIDS information
Initial for drug/alcohol diagnosis, treatment, or referral
Final Consent
I understand that I am not required to sign this authorization. If I refuse to sign this, it will not prevent me from getting mental health treatment at Northwest ADHD Treatment Center. The only exception is if the services I am seeking are only for providing health information to someone else and this authorization is needed to make the disclosure. I may revoke this authorization in writing at any time. If I revoke this authorization, the information described may no longer be used or disclosed for the purposes described here. If Northwest ADHD Treatment Center has already used or disclosed the information, that cannot be undone. I understand that the information used or disclosed as a result of this authorization may be subject to re‐disclosure and no longer protected under federal law. However, I also understand that federal or state law may restrict re‐disclosure of HIV/AIDS, mental health information, genetic testing information, and drug/alcohol diagnosis, treatment or referral information. To revoke this authorization please send a written statement to the office manager at the address or fax number listed above and state that you are revoking this authorization. Unless revoked, this authorization expires 90 days after the completion of treatment. You can revoke this release by sending written notice to our office staff or your provider.
Patient Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Today's date
Expand to add a Patient Guardian/ Authorized Representative
Patient's Guardian/ Authorized Representative Information
The following section only needs to be completed if someone other than the patient has legal authority to schedule appointments and make care decisions about the patient. This includes parents if a patient is a minor.
Parent / Guardian / Representative Signature
Parent / Guardian / Representative Name
First Name
Last Name
Parent / Guardian / Representative Relationship to Patient
Parent, Legal Guardian, Caregiver, Etc.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Today's date
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Records Release Request to Self
Northwest ADHD patients are entitled to access to their full records at any time. You may use this form to request all or part of your health information on file to date. Your health information may also be available to you already through your portal account. We need your permission to release any records from our facility. By signing this form you authorize Northwest ADHD Treatment Center to release your records to you. A separate form is required to release your records to a third party. **Your provider may follow up to discuss rationale for and implications of personally requested records.
Patient Name
First Name
Last Name
Patient Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
I am request the following of my OWN health records from NW ADHD
Please initial all that apply:
Initial for diagnostic verification letter
Initial for treatment plan
Initial for progress notes
Initial for other (please describe)
I authorize my records to be released to myself through the following method(s)
Please initial
Initial for records to be released through my patient portal account
Initial for records to be released by email
Email address to release records
example@example.com
Initial for records to be released by mail
Initial for records to be released via fax
Fax number to release records
Please enter a valid fax number.
Format: (000) 000-0000.
Initial for records to be released on flash drive
Provided by patient and must be new in unopened package
Initial for records to be released in person
If you are requesting to pick up your records in person, you must present valid, non-expired, ID and sign an additional release form with the front desk before records will be released.
I understand that I am not required to sign this authorization. If I refuse to sign this, it will not prevent me from getting mental health treatment at Northwest ADHD Treatment Center. The only exception is if the services I am seeking are only for providing health information to someone else and this authorization is needed to make the disclosure. I may revoke this authorization in writing at any time. If I revoke this authorization, the information described may no longer be used or disclosed for the purposes described here. If Northwest ADHD Treatment Center has already used or disclosed the information, that cannot be undone. I understand that the information used or disclosed as a result of this authorization may be subject to re‐disclosure and no longer protected under federal law. However, I also understand that federal or state law may restrict re‐disclosure of HIV/AIDS, mental health information, genetic testing information, and drug/alcohol diagnosis, treatment or referral information.To revoke this authorization please send a written statement to the office manager at the address or fax number listed above and state that you are revoking this authorization. Unless revoked, this authorization expires 90 days after the completion of treatment. You can revoke this release by sending written notice to our office staff or your provider. The records I’m requesting contain protected health information (PHI), which is confidential and sensitive. Once these records are released into my possession, it is my sole responsibility to safeguard their privacy and confidentiality. NW ADHD is no longer liable for the protection, security, or unauthorized disclosure of this information once it has been released to me. If these records are lost, stolen, copied, shared, or otherwise misused after they are released, NW ADHD cannot be held accountable. I am responsible for proper and secure storage, use, and disposal of these documents.
Patient Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Todays' date
Expand to add a Patient Guardian / Authorized Representative
Parent / Guardian / Representative Signature
Parent / Guardian / Representative Name
First Name
Last Name
Parent / Guardian / Representative Relationship to Patient
Parent, caregiver, etc.
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Please click submit for your request to be completed. Thank you!
Submit
Submit
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