Release of Information/Divulgación de información

¿Habla español? Seleccione español en la esquina derecha de esta página.
Patient Information
First Name*
Middle Initial
Last Name*
Maiden or Other Known Name
Date of Birth*

MonthDayYear
Date
Home Address
Daytime Phone
Parent/Guardian
Information to be Released
I give permission for Roots Wellness Center to exchange information with the following entity:
Name*
Address*
City, State, ZIP*
Phone*
Fax
Relationship to client*
Important: Indicate only the information that you are authorizing to be released.
All Health InformationSpecific dates/years of treament
OR only release specific portions of your health information. Indicate categories to be released:

History/PhysicalDiagnostic AssessmentDischarge SummaryEvaluationsProgress NotesFunctional AssessmentBilling RecordsInsurance InformationOther
Health information includes written and oral information. By indicating any of the categories above, you are giving permission for written information to be released and for the above ensures to speak with each other about your health information. If you DO NOT want to give your permission for verbal communication please initial here.
Reason(s) for releasing information. Please choose one or more.

Review client's current careClient's requestTreatment/continued carePaymentLegalSocial Security AdministrationOther
I understand that by signing this form, I am requesting that the health information specified on this form be exchanged with the third party named on this form. I may stop this consent at any me by writing to the organization(s), facility(ies) and/or professional(s) named above. If the organization, facility or professional named above has already released health information based on my consent, my request to stop will not work for that health information. I understand that when the health information specified above is sent to the third party named above, the information could be re-disclosed by the third party that receives it and may no longer be protected by federal or state privacy laws. I understand that if the organization named above is a health care provider they will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign the consent form.

This Consent will end one year from the date the form was signed unless I indicate an earlier date or event here:
Earlier Date

MonthDayYear
Date
Or Specific Event
Please sign below as the Client or Authorized Representative. The form will only require one signature.
Client Signature*

Clear
Date

MonthDayYear
Date
Authorized Representative's signature*

Clear
Date

MonthDayYear
Date
Printed Name*
Relationship to Client*
Witness Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Patient Information

Information to be Released