Release of Information – Roots Client Signs WPForm Please enable JavaScript in your browser to complete this form.Your InformationPlease fill out the form below to setup your release. Client Name *FirstLastClient Date of Birth *Client Email (you will receive a signed copy of the authorization) *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 ContactBusiness/AgencyAgency/Organization NameAt least one of Agency/Organization Name or Contact Name is requiredContact NameFirstLastRequired if "Personal Contact" is selected above.Contact PhoneAddress 1Address 2CityStateZipContact EmailNature of Information Exchange:How may we exchange information with this contact? *provide toreceive fromexchange withWhat type of information may we exchange? *Assessments/SummariesChemical Health InformationDiagnosisEmergency ContactMedical History and Physical Neuropsychological / Psychological TestingTreatment Plans and ReviewsCase Plan/NotesConsultsDischarge SummaryLegalMedications/DosageProgress/Group NotesUA/LabsOther:The most common options are pre-selected. Change the options as needed.In what format may we exchange information? *VerballyIn-person conferenceWritten QuestionnaireMailed or Faxed CorrespondencePurpose for disclosure: *Assessment/IntakeReferralTreatment PlanningCase CoordinationDischarge/Continuing CareConsultationOtherExpiration of Release of InformationTypically, 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.Expiration DateI Don't Need to Change the ExpirationEnter a Different DateExpiration DateMessageProceed to Signature Page
