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,



Information to be disclosed:

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

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Signature Certificate
Document name: ROI Form
lock iconUnique Document ID: 0354c6045f5daad5d4d27479cc18073299d3d96f
Timestamp Audit
June 18, 2022 9:48 am CDTROI Form Uploaded by BMH Front Desk - IP