Authorization for Disclosure of Protected Health Information

Release of Information Form (ROI)

Patient Name:(Required)

Date of Birth:(Required)

Parent/Guardian Name:(Required)

As the person signing this authorization, I understand that:

The provision of treatment or payment cannot be conditioned on my signing of this authorization.
Any health information re-disclosed by the recipient may no longer be protected by this authorization.
The original or copy of the authorization shall be included in the medical record.

I am authorizing Good Beginnings, Inc. (Provider) to disclose my health information to the following organization(s) or person(s) specified below:

Organization(s) or Person(s):(Required)

Information to be disclosed:

Contact information for above (email):(Required)

Method of disclosure (Mailed, Emailed, Verbal, etc.):

Purpose for disclosure:

Additional Details as needed:

Printed Name:(Required)

Date(Required)

Signature(Required)

Relationship to Patient:(Required)

If you prefer to fill out this form by hand, you can download the PDF version here: Download Authorization Form PDF. Once completed, please print, sign, and return it to us.