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ROI Form

I authorize (please type "Dr. Cook's Office") to release/obtain the protected health information, including records of mental health services, and/or substance abuse treatment,

of:

Patient Name:
Date of Birth:
Address:
Phone:

to:

Name of Institution:
Address:
City, State, Zip:

Information to be disclosed:

Date(s) of Service:

Psychiatric assessment

Psychiatric progress notes, with medication list

Purposes for Use and/or Disclosure:

At the request of the individual

Legal Purposes

Insurance

Coordination of Care

Other:

*Unless otherwise revoked, this authorization will expire on the following date or event: ________. If a date or event is not specified, this authorization will expire one year from my date of signature below.

This authorization is voluntary. I understand that I can refuse to sign this authorization and Dr. Cook’s Office will not condition my treatment or payment on the signing of this authorization except as allowed under federal privacy laws for: a) research-related treatment, or b) mental health care provided solely for disclosure to a third party. I understand that I may revoke this authorization at any time by notifying Dr. Cook’s Office, in writing, of my revocation. I understand that the revocation will not apply to any information that already was released in reliance on this authorization. I understand that the health information released under this authorization may be re-disclosed by the recipient and may no longer be protected under federal privacy regulations.

I hereby release Dr. Cook’s Office from all liability and all claims of any nature whatsoever pertaining to the disclosure of information, or of any professional opinions, or recommendations as contained in the records released to or by Dr. Cook’s Office.

Relationship:

(relationship to patient) *complete only if requestor is not patient

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I understand this is a legal representation of my signature

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Timestamp

Audit

June 18, 2022 9:48 am CDT

ROI Form Uploaded by BMH Front Desk - frontdesk@beyond-mh.com IP 173.175.118.194