Release of Information

When you are requesting medical records for another provider to release to Teri's Health Services the records can be sent to below fax which is the preferred method of release from one entity to Teri's Health Services. If you are a patient providing medical records please upload them into your consent link or provide to our office by emailing records@terishealthservices.org. If you are requesting records after completing this form please also send email to records@terishealthservices.org

When involved in family or couples/marriage therapy our office requires a release of information be completed between each party. The reason is Teri's Health Services has one shared chart for a family counseling or couples/marriage counseling treatment option. This ROI allows for either party in the counseling forum to request records at any time without redactment of the chart.

*Exchange of information can be verbal or written exchange.

Patient Name

First NameLast Name

Name of Person Completing this Form

First NameLast Name

Patient Date of Birth

Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Patient Email:

example@example.com

Select the one that best matches your purpose of completing an ROI

1. Select the one that best matches your purpose of completing an ROI (select the option that best matches your choice now)

I am requesting a release of my own records or the records of my dependent. If for self or dependent child or adult, state person who is to receive the forms. If you (patient) are wanting your own documents place your first and last name. If requesting your own records, we share records through the secure patient portal. If you want us to not share through the portal please indicate that in below text box for what you are requesting forms for.

2. If you selected more than one option above please state here what you are requesting now for our office to do. If ROI to be held on record only, state on record only.

3. Full name of person or entity/agency to release and/or exchange information with. If you are filling this form out for family/couples marriage counseling please complete one per person and place the person's name in this section

4. The individual, agency, or entity requesting or receiving the record or information. If this is for family or couples counseling please place here the same name you stated in question 3.

If applicable. Place the address of the entity or person listed in Box 3.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If applicable. Place the phone number of the entity or person listed in Box 3.

Please enter a valid phone number.Format: (000) 000-0000.

If applicable. Place the fax number of the entity or person listed in Box 3.

Please enter a valid phone number.Format: (000) 000-0000.

Release or exchange information start date (what date of service do you want release of records to start?).

Date

Release or exchange information start date (what date of service do you want release of records to end?; will end at 12 months or before if a date prior to 12 months is stated)

Date

Consent to Release or Exchange Information

I understand that information in my health record may include information relating to Sexually Transmitted Disease, Acquired Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV), and other communicable diseases, Behavioral Health Care/Psychiatric Care, treatment of alcohol and/or drug abuse and genetic testing. My signature authorizes release of any such information.

I understand that I may revoke this authorization at any time. I understand that I have a right to receive a copy of this authorization.

This Authorization pertains to the information and dates specified on this Authorization. Unless I revoke this authorization earlier, it will expire 12 months from the date signed. I understand that if this information is disclosed to a third party, the information may no longer be protected by state, federal regulations and may be re-disclosed by the person or organization that receives the information. I release Teri's Health Services, its employees and agents, medical staff members and business associates from any legal responsibility or liability for the disclosure of the above information to the extent indicated and authorized herein.

NOTE: There is a level of risk that a third party could access your Protected Health Information (PHI) without your consent when faxed or when electronic media or email is unencrypted. We are not responsible for unauthorized access to faxes, unencrypted media or email or for any risks (e.g., virus) potentially introduced to your computer/
device when receiving PHI in any electronic format or email.

Your authorization of this release of information can be revoked or canceled at any time without questions asked or punitive results.

Consent to Release:

A description of the client record or information to be released or disclosed.

What is the reason for record exchange:

Date to Release Records:

Type of release you are consenting to (select all that apply). If this form is being completed for couples/marriage and/or family counseling please select option "Keep ROI on Record"

Other

Do you consent to exchange of information through verbal means (phone call, in person contact, or other form of communication verbal)?

Method of exchange you are requesting at this time for us to complete. If you consent for all select all.

Provide Delivery Specific directions for delivery here or anything else needed to note to us. Or state N/A

Patient Name

First NameLast Name

Patient Signature

Today's Date

Date

Guardian Name

Guardian Signature

Date

Please send records to:

Teri's Health Services

14040 N. Cave Creek Rd. Suite 205 Phoenix Az 85022

Phone: 602-358-7073 Fax: 888-927-0409

Authorization for the Release or Exchange of Information