Roots Release of Information - Client Self-Service Use this form to request that your client or their parent/guardian sign a release of information. Today's Date* MM slash DD slash YYYY Client Name:* First Last Client's Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Client eMail:* Agency/Person for whom the release is being signedAre you signing a release for a personal contact like a significant other, or a business/agency? * Personal Contact Business/Agency Agency Name:Required if "business/agency" is selected above. Contact Person's Name:Required if "personal contact" is selected above. First Last Contact Phone:Contact eMail: Contact or Business/Agency Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Nature & Purpose of DisclosureHow may we exchange information with this contact? ** provide to receive from exchange with What type of information may we exchange?*The most common options are pre-selected. Please check/uncheck options to match your preference. Assessments/Summaries Chemical Health Information Diagnosis Diagnostic Interview Medical History & Physical Neuro/Psychological Testing Case Plans/Notes Discharge Summary Medication Information Urinalysis/Lab Tests Emergency Contact Treatment/Case Plans Consultations Legal Information Psychotherapy Notes Other Other information type: In what format may we exchange information?* Verbally In-Person Conference Written Questionnaire Mailed/Faxed Correspondence Secure/Encrypted eMail Purpose for disclosure:* Assessment/Intake Referral Treatment Planning Case Coordination Discharge Planning Consultation Psychotherapy Expiration of AuthorizationTypically, releases of information automatically expire one year from the date signed. This allows us to share the necessary information for the duration of treatment involvement. If you wish to specify an earlier date of expiration, you may do so here. I Don't Need to Change the Expiration Enter a Different Date Alternate Expiration Date MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. Δ
