Healthcare IOP ROI Template

Intensive Outpatient Program - Release of Information (ROI)

Purpose: The undersigned authorizes the disclosure of protected health information as described below. This authorization is voluntary and the information disclosed may include behavioral health, substance use disorder treatment, and other sensitive records as indicated.

Patient Identification

Patient Name:    Date of Birth:

Recipient of Information

Phone:    Fax:    Email:

Records to Be Released

Select specific records to disclose (check all that apply):

Treatment summary / diagnosis

Progress notes / group notes

Assessments / intake evaluation

Medication records / prescriptions

Discharge summary / aftercare plan

Laboratory and toxicology results

Billing and payment information

Psychotherapy notes (explicit authorization required)

Purpose of Disclosure

Purpose (select all that apply):

Continuing care / referral

Insurance / benefits management

Legal representation / court involvement

Personal use / patient request

Method of Disclosure

Send records via:

Mail (to recipient address)

Fax    Fax number:

Secure email    Email:

Pick up in person

Electronic record transfer / portal

Authorization Period and Expiration

This authorization is effective from:    Expires on:

Alternatively, expiration may be defined as:

Special Notice Regarding Sensitive Information

I understand that records related to behavioral health, psychotherapy notes, and substance use disorder treatment may be subject to special confidentiality protections. Psychotherapy notes will be released only if I have specifically authorized release above. Federal and state law may restrict redisclosure of substance use disorder treatment information; such information may not be disclosed further without my explicit consent except as permitted by law.

Redisclosure, Revocation and Fees

Redisclosure: I understand that once my protected health information is disclosed to the recipient named above, it may be subject to re-disclosure and no longer protected by the disclosing organization’s privacy policies, except where prohibited by law.

Revocation: I may revoke this authorization at any time by submitting a written revocation to the releasing facility, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures made prior to receipt of the revocation.

Fees: I understand that reasonable fees may be charged for copying and mailing records in accordance with applicable law.

Acknowledgment of Rights

By signing below I acknowledge that I have read and understand this authorization, that the disclosure authorized is voluntary, and that I may request a copy of this authorization after I sign it. I authorize the release of the records described above for the purposes stated.

I acknowledge receipt of the facility's Privacy Notice: (check to acknowledge)

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