Release of Information (ROI)

Release of Information (ROI)
Authorization to Use or Disclose Protected Health Information

This authorization form implements the requirements for client authorization to use and disclose health information protected by federal health privacy law (45 C.F.R. Parts 160,164), the federal drug and alcohol confidentiality law (42 C.F.R. Part 2), and the state confidentiality law governing mental health, developmental disabilities, and substance abuse services (G.S. 122 CC-52 through 122C-56) as well as the HIV/AIDS information (NC General Statute 130A-143) and Substance Abuse information (42CFR Part 2).
Information to be Released *

TO Carolina Behavioral Care FROM the below listed entity. FROM Carolina Behavioral Care TO the below listed entity.
ROI Direction (Hidden):

TO FROM
ROI Inverse Direction (Hidden):

TO FROM
Patient's First and Last Name: *
Last Four Numbers of Client/Patient's Social Security Number:
Date of Birth: *

Month Day Year
Dates of Treatment to Authorize for Use or Disclosure: *

Specific Dates of Treatment All Dates of Treatment
Specific Dates of Treatment:
Month Month* / Year Year*
All Dates of Treatment (Type Initials Here): *
Release of Information {roiInverse}:
Name of Contact Person: *
Business Name:
Address:

Street

Street Address Line 2

City, State Zip
Telephone Number: *
Fax Number:
Release of Information {roiDirection}:

Carolina Behavioral Care
PO Box 1630
Pinehurst, NC 28374

Fax Number: 877-256-8588
Tele Number: 844-534-7208
Purpose of Release: *

Continuity of Care Insurance Legal Representation Request of the Individual Other
Medication Records: *

Assessments Psychosocial Assessment Psychotherapy Notes Psychiatric Evaluations Medication Records HIV/AIDS Information Psychological Evaluations Progress Update/Verbal Substance Abuse/Treatment Financial Other
The person completing this form is the client/patient: *

Yes No
The patient signs by mark (if signing by mark, a witness's signature and printed name will be required): *

Yes No
If you are signing below on behalf of the client/patient, please specify the basis of your authority (i.e.: Guardian, Parent of a Minor, Power of Attorney, Other Authorized Representative): *
Documentation verifying your authority may be required.
In the field below, please provide documentation verifying your authority to sign on behalf of the client/patient: *

Cancel of
I understand that I may revoke or terminate this authorization at any time by submitting a written revocation to Carolina BehavioralCare, except to the extent that action has already been taken in reliance there on. If not previously revoked, this authorization will expireone year from the date of signature.

I understand that information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. The privacy of this information may not be protected under the federal privacy regulations.

I understand that I may inspect or request a copy of information that is used or disclosed under this authorization and I may refuse to sign this authorization. If I refuse to sign this authorization Carolina Behavioral Care will not deny or refuse to provide treatment, payment, enrollment in a healthplan, or eligibility for benefits if I refuse to sign.
Signature of Patient *

Clear
Signature of Witness *

Clear
Printed Name of Witness: *
Signature of Authorized Representative *

Clear
Authorized Representative's Relationship to Patient: *
Authorized Representative's Telephone Number: *
Please enter a valid phone number in the event we need to contact you for further information.
Should be Empty: