The authorization for release of information (ROI) form is designed to gain parent/legal guardian consent to acquire confidential information by submitting permission to another program/agency that maintains confidential information for the purposes of record review and file completion.
I authorize the release and/or exchange of confidential information to: Unique Pathways, LLC313 W. Wall Street, Suite 200Grapevine, TX, 76051 I understand that Unique Pathways has an obligation to keep all personal information, identifying information, and my records confidential. Furthermore, the parent/legal guardian understands the following:
o I do not have to sign this release form and that any signature on this form is voluntaryo Releasing information involves giving information about myself and could give another entity or person access to personal identifying informationo This form has the same force and effect if photocopiedo I can rescind this authorization any time by written notificationo Unique Pathways and I may not be able to dictate the outcome of sharing information with another entity or person and that my information may be requested by law from the entity or person whose information was released o The release is limited to the person(s) and/or entities specified belowo Records will be shared using the easiest means necessary (fax, email, etc.) This release will expire one year from the date of authorization specified above OR from the date indicated here: _________________________ (Date)
The following person(s) and/or entities to release and/or exchange any information requested by Unique Pathways: