Release of Information (ROI) Authorization

Optimum Behavioral Health & Wellness, LLC

Patient Name: ___________________________
Date of Birth: ___________________________
Phone Number: ___________________________

I hereby authorize Optimum Behavioral Health & Wellness, LLC to:
☐ Release information to  ☐ Obtain information from  ☐ Exchange information with

Name/Organization: __________________________________________
Address/Phone/Fax: __________________________________________

Type of Information to be Released/Obtained (check all that apply):
☐ Treatment/Progress Notes
☐ Assessment/Evaluations
☐ Medication/Medical Information
☐ Billing/Insurance Information
☐ Other: ___________________________

Purpose of Disclosure:
☐ Coordination of Care ☐ Insurance/Payment ☐ Legal ☐ Personal Request
☐ Other: ___________________________

Expiration:
This authorization is valid until: ______________________ (date)
OR ☐ One year from the date of signature

Right to Revoke:
I understand that I may revoke this authorization at any time by providing written notice to Optimum Behavioral Health & Wellness, LLC. Revocation will not affect any information already released.

Redisclosure:
I understand that once information is disclosed, it may no longer be protected by federal privacy laws (HIPAA).

Signature of Patient/Legal Guardian: ___________________________
Relationship (if not patient): ___________________________
Date: ___________________________