Is an electronic signature valid on this form?

Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. §7001) and UETA in most states provided the four ESIGN criteria are met: intent to sign, consent to transact electronically, attribution of the signature to the signer, and record retention capable of reproduction.

Do I need a HIPAA authorization format?

Where PHI is involved, the authorization should meet HIPAA content requirements and include specific elements; psychotherapy notes require a separate, explicit authorization. Providers often require HIPAA-compliant language prior to release.

Can I revoke the authorization later?

Yes. The patient may revoke a HIPAA authorization in writing, but revocation does not affect disclosures already made in reliance on the authorization prior to receipt of the revocation.

When is notarization required?

Most ROI forms do not require notarization, but state or institutional policies may ask for notarized signatures or witness attestations for representative signers or certain mental health records; verify local rules.

What if the signer is an authorized representative?

Attach documentation proving authority (durable power of attorney, guardianship order, or similar). Providers will withhold release until authority is verified.

How does signNow support HIPAA and secure ROI workflows?

signNow supports HIPAA through a Business Associate Agreement (BAA) option, provides audit trails, and secures data with TLS 1.2/1.3 in transit and AES-256 at rest; request a BAA to meet provider compliance requirements.

Electronic Signature
Templates
Healthcare
Healthcare NAMI ROI Form

Healthcare NAMI ROI Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Healthcare NAMI Release of Information (ROI) Form

Patient Information

Patient Name

Date of Birth

Gender (check applicable)

Male Female Other

Address

Primary Phone

Email

Emergency Contact

Insurance Information (if applicable)

Insurance Provider

Policy Number

Group Number

Subscriber Name

Authorization to Release Information

I hereby authorize the disclosure of my protected health information as described in this form. I authorize: to release the following information to:

Recipient name/organization:

Recipient address / contact details Purpose of Disclosure (check all that apply)

Continuing treatment / coordination of care Insurance / Billing / Payment Legal / Court Personal use by patient Research (if checked, purpose and limitations below)

Information to be released (check all that apply)

Complete medical record (including mental health records) Treatment summary / discharge summary Progress notes Medication records / prescriptions Laboratory reports / diagnostic testing Billing / claims information Substance use treatment records Psychotherapy notes (see special authorization below)

Special Note: Psychotherapy notes are treated differently under privacy rules and may require specific, separate authorization. If psychotherapy notes are requested, the patient acknowledges a separate review of the consequences of releasing such notes.

Method of Disclosure

Mail Fax Electronic / Email / Portal In-person pickup Other

Expiration and Revocation

This authorization will expire on: OR upon occurrence of the following event:

I understand that I may revoke this authorization at any time by providing a written notice of revocation to the disclosing entity identified above. Revocation will not apply to information already released in reliance on this authorization prior to receipt of the revocation.

Revocation contact (to revoke authorization)

Rights & Notices

I understand that signing this document is voluntary. Treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization unless allowed by law. I understand that information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by federal or state privacy laws.

I understand I have the right to inspect and obtain a copy of the records to be disclosed, and that the disclosing entity may charge reasonable fees for copying and postage in accordance with applicable law. I understand that I may refuse to sign this authorization and that I may request a copy of the signed form.

Copy fees (if any) — acknowledgement

I acknowledge I may be charged reasonable copying fees. No fees expected

Additional Authorizations & Limitations

Limit disclosure to specific dates, providers, or types of information Other statements / special instructions

HIPAA Acknowledgment

By signing below I acknowledge that I have read and understand this authorization and that it meets the requirements of applicable privacy laws. I understand the uses and limits of this authorization and consent to the release of the information described above.

Consent to receive records electronically (if selected)

I consent to the release of my records via unencrypted electronic transmission where necessary, with an understanding of the potential risks.

Certification

I certify that the information I have provided on this form is true and correct to the best of my knowledge. I understand that false statements may be subject to applicable legal penalties.

Patient Name:

Signature:

Date:

If signed by legal representative / guardian, state relationship Representative printed name (if applicable)

What the Healthcare NAMI ROI Form Is and When it’s Used

The Healthcare NAMI ROI Form is a patient authorization (release of information) used to permit disclosure of behavioral health or mental health records to the National Alliance on Mental Illness (NAMI), a named third party, or a designated representative. It documents the patient’s informed consent to share protected health information (PHI) for a stated purpose, scope, and time period. The form typically references HIPAA requirements for authorizations, specifies the types of records to be released, and records signature, date, and any revocation provisions required by law.

Why a Clear NAMI Release of Information Matters

A completed Healthcare NAMI ROI Form establishes legal consent for health data sharing, clarifies what information may be shared and for how long, and reduces administrative delays. Properly executed authorizations support continuity of care, advocacy engagement, and compliance with HIPAA privacy rules.

Who Typically Completes and Receives This Form

Proper role assignment ensures the form is completed by an authorized signer and routed to records staff for secure handling.

Patients or legal guardians requesting advocacy support, benefits assistance, or peer services from NAMI or other advocates.
Behavioral health clinics and medical records teams releasing specified PHI to a named third party.
Care coordinators and case managers who need documented consent to exchange records across organizations.

Essential Components of a Professional Healthcare NAMI ROI Form

A compliant ROI form combines clear identification, specific scope, temporal limits, signature authentication, and revocation details so requests are processed reliably by health providers and third parties.

Patient Identity

Full legal name, date of birth, and medical record number. Include current address and a government ID reference to avoid mismatched records and ensure correct patient matching.

Recipient Details

Name of NAMI chapter or other recipient, complete mailing or electronic delivery address, and contact information so records are routed to the correct organizational unit or advocate.

Scope of Records

Specific categories (progress notes, psychotherapy notes, medication lists, lab results). Avoid vague phrases; identify date ranges or precise document types to limit overbroad disclosure.

Purpose for Disclosure

State the reason (peer support, benefits application, legal advocacy). Purpose clarifies necessity and helps reviewers determine whether the request meets internal privacy standards.

Expiration and Revocation

Specify an expiration date or event and include instructions for how the patient may revoke authorization, noting that revocation may not affect disclosures already made.

Signature and Authentication

Dated written or electronic signature of the patient or authorized representative; if signed by a representative, attach proof of authority (power of attorney, guardianship documentation).

Required Fields and Key Data Elements

Patient Name: Full legal name

Date of Birth: MM/DD/YYYY

Recipient: Name and contact

Record Types: Specified categories

Expiration: Expiration date

Signature: Signer and date

Step-by-Step: Completing the Healthcare NAMI ROI Form

Follow these steps in order to ensure the form is valid and processed promptly by health records staff.

01

1. Identify Patient: Enter full legal name and DOB exactly.
02

2. Specify Recipient: Provide full NAMI chapter contact details.
03

3. Limit Scope: List specific record types and date ranges.
04

4. Sign and Date: Patient or authorized rep signs and dates form.

Configuring an Online ROI Workflow

Set up clear fields, signer authentication, and delivery rules when completing the form electronically.

Field	Configuration
Patient Identity	Required text field with validation
Recipient Contact	Structured fields for name, phone, email
Record Categories	Checkbox list with 'other' option
Signature	Electronic signature field with date stamp

Technical Considerations for eSubmission and Storage

Proper platform configuration reduces processing errors, preserves an auditable signature record, and helps meet HIPAA and audit requirements.

Formats Supported: PDF, DOCX, and secured image formats
Integrations: Connectors to EHRs and cloud storage
Authentication: Email, SMS code, or stronger options

How Records Are Routed After You Submit the Form

Submission triggers a short workflow: records office review, release authorization check, redaction if necessary, and secure delivery to the recipient.

Records Office Review: Verify identity and scope of requested records
Authorization Check: Confirm signature authority and revocation status
Redaction: Remove unrelated third-party identifiers as required
Secure Delivery: Send via encrypted email, secure portal, or physical mail

Typical Timelines and Statutory Response Deadlines

Know statutory response windows and typical processing times to set expectations for patients and advocates.

Acknowledgment Time:

Provider typically acknowledges request upon receipt.

HIPAA Response Window:

Providers must act within 30 days (45 CFR §164.524(b)(2))

Extension Possibility:

One 30-day extension allowed with written notice

Expedited Requests:

May be prioritized for urgent care or legal deadlines

Delivery Time:

Secure electronic delivery often completes within days

Common Mistakes That Delay Processing

Incomplete or nonmatching patient identifiers cause record-search delays and potential denials.
Overbroad authorizations lack clear dates or record categories, prompting additional provider review.
Missing proof of representative authority results in refusal to release records to third parties.
Using nonsecure delivery instructions exposes PHI and may violate provider policies or HIPAA.

Risks and Consequences of Improper or Incomplete Authorizations

Denied Release: Provider may refuse release until corrected

HIPAA Complaint: Patient can file with HHS OCR

Civil Liability: Improper disclosures risk civil claims

Care Delays: Lack of records can delay treatment

Revocation Gaps: Revocations do not undo prior disclosures

Record Integrity: Incomplete forms create audit and compliance issues

eSignature Pricing and Feature Comparison for Health ROI Workflows

Compare basic price and core capabilities for common eSignature vendors when handling sensitive healthcare releases. Prices reflect typical per-user monthly rates under annual billing.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	Varies
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions About the Healthcare NAMI ROI Form

Answers to common concerns about validity, revocation, electronic signing, and secure delivery for ROI forms used with NAMI or similar advocacy organizations.

Need help? Contact support

Is an electronic signature valid on this form?
Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. §7001) and UETA in most states provided the four ESIGN criteria are met: intent to sign, consent to transact electronically, attribution of the signature to the signer, and record retention capable of reproduction.
Do I need a HIPAA authorization format?
Where PHI is involved, the authorization should meet HIPAA content requirements and include specific elements; psychotherapy notes require a separate, explicit authorization. Providers often require HIPAA-compliant language prior to release.
Can I revoke the authorization later?
Yes. The patient may revoke a HIPAA authorization in writing, but revocation does not affect disclosures already made in reliance on the authorization prior to receipt of the revocation.
When is notarization required?
Most ROI forms do not require notarization, but state or institutional policies may ask for notarized signatures or witness attestations for representative signers or certain mental health records; verify local rules.
What if the signer is an authorized representative?
Attach documentation proving authority (durable power of attorney, guardianship order, or similar). Providers will withhold release until authority is verified.
How does signNow support HIPAA and secure ROI workflows?
signNow supports HIPAA through a Business Associate Agreement (BAA) option, provides audit trails, and secures data with TLS 1.2/1.3 in transit and AES-256 at rest; request a BAA to meet provider compliance requirements.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now