Release of Information Form

We take confidentiality seriously. We are offering patients the option to electronically request Release of Information (ROI) to and from other providers/loved ones (i.e. therapists, primary care doctors, family members). Please fill out the form below and electronically sign to allow us permission to share medical information. Please click on “Submit Release of Information” button when complete.

Your Name

Date of Birth

YYYY

Best Phone Number to Reach You

(###)

###

####

Other Provider/Loved One: Information #1 (Name, Fax, Phone)

Other Provider/Loved One: Information #2 (Name, Fax, Phone)

Name of your provider(s) at AustinPsychCare

I am allowing the following information to be shared between medical providers

Further comments/instructions (optional- i.e. release my medical records; this is my therapist; this is my spouse) )

Electronic Signature (Please type in first and last name here)

Today's Date

YYYY

Please check all of the following:

I am electronically signing the request for Release of Information (ROI) between Austin PsychCare and the provider(s) above.

I understand that ROI can be rescinded at any time with a written request.