Awakened Roots: Release of Information

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Please complete this ROI if you'd like me to communicate with anyone else regarding your treatment (case worker, therapist, family, supporters). This is not required.

Email *

Client's Full Legal Name *

Date of Birth *

YYYY

I authorize Gregory Payne, CLC at Awakened Roots LLC to (check one or both):
*

Send

Receive

Required

The following information
*

Intake Information

Session Notes

Session Progress

Emergency Information

Other:

Required

To / From (Name of Person or Agency)
*

Phone
*

Fax

Person/Agency's Relationship to Client
*

Self

Parent/legal guardian

Personal representative

Other:

Required

The above information will be used for the following purposes (check all that apply)
*

Coordinating care

Determining eligibility for benefits or program

Case review

Updating files

Other:

Required

I understand that this information may be protected by Title 45 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 42 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules.
I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, and after (some states vary, usually 1 year) this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information. I understand that I have a right to receive a copy of this authorization. I understand that I have a right to refuse to sign this authorization.
If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.

Signature of Client/Parent/Guardian

*this represents my electronic signature

Today's Date *

YYYY

Witness signature (if client is unable to sign)

Witness Date

YYYY

A copy of your responses will be emailed to the address you provided.

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