ROI Form Organizations

AUTHORIZATION TO RELEASE/EXCHANGE INFORMATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I,First Name* Last Name* , authorize Case Manager's Name* of Kindness Initiative (hereinafter “Provider”) to disclose/exchange protected health information and records obtained in the course of receiving Case Management services, including, but not limited to the following:
Such disclosure shall be limited to the following specific types of information (Check all that apply):*

AdvocacyResource CoordinationAssessmentService PlanningDates of ServiceGeneral Demographic InformationOther
Organization Information

Please fill out information that pertains to the organization with which you are authorizing Kindness Initiative to release information.
Name of organization*
Name of Contact (if applicable):
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Rights

I understand my records are protected under federal regulations and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I can refuse to sign this authorization. I understand that I may inspect or obtain a copy of the information used or disclosed, as provided in 45 Code of Federal Regulations section 164.524. I understand that I have the right to revoke this authorization at any time. I understand that the revocation will not apply to information that has already been released based on this authorization. Any revocation or modification of this authorization must be in writing and received by Provider at 9404 Genesee Ave #200, La Jolla, CA 92037.
This authorization will remain valid through:

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Date
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AUTHORIZATION TO RELEASE/EXCHANGE INFORMATION

Organization Information

Rights