Roots Wellness
Center
(612) 289-5656
info@rwc-mn.com
393 N Dunlap St, Ste #300, St Paul
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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
*
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Client eMail:
*
Agency/Person for whom the release is being signed
Are 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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
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New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Nature & Purpose of Disclosure
How 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 Authorization
Typically, 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
Name
This field is for validation purposes and should be left unchanged.
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Minnesota CarePartner/Roots Recovery is now
Roots Wellness Center
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