ROI Form

"*" indicates required fields

Address*

AUTHORIZATION FOR USE OR RELEASE OF PROTECTED HEALTH INFORMATION INCLUDING CONFIDENTIAL HIV RELEATED INFORMATION

CONFIDENTIAL

If the requested portion of the record contains information on pertaining to drug or alcohol treatment or contains HIV related information, you must specifically consent to the release of such information by initialing one or both of the following:

I understand that if my record contains information concerning psychiatric, drug and alcohol treatment; such information will be released pursuant to the consent.

I understand that if my records contain confiden al health informa on, such informa on will be released pursuant to this consent form. Confidential HIV related information is any information indicating that a person ad an HIV related test, or has HIV infection, IV related illness, AIDS, or any information which could indicate that a person has been potentially exposed to HIV.

Clear Signature

I hereby authorize NEW DIRECTIONS to release:

ND Address Release*

I hereby authorize:

Person-Agency Address Release*

to release information pertaining to my record to NEW DIRECTIONS. For the purpose of:

Release Purpose*

I limit the information to be released to the following items:

Release Purpose*
Covering Records (from date)*
Covering Records (to date)*
Clear Signature
Date*