TendForm

Release of Information (ROI) Authorization template

A free release of information (ROI) authorization template: who may share, what may be shared, purpose, expiration date, and the client's right to revoke. Clients complete and sign it online.

Release of Information (ROI) Authorization

Client

Client full name *

Client date of birth *

Who may share and receive information

I authorize [Practice Name] to exchange information with the person or organization below.

Name of person or organization *

Their role *

Primary care provider

Psychiatrist

Other therapist or counselor

School

Family member

Attorney

Other

Their phone, fax, or email *

Direction of the exchange *

Release my information to them

Receive information from them

Both

What may be shared

Anything specific to include or exclude

Purpose of the exchange *

Coordination of care

Continuity of care

Legal

School planning

At my request

Other

Expiration and your rights

This authorization expires on *

You may revoke this authorization at any time by writing to [Practice Name], except for information already shared. Your treatment does not depend on signing this form. Information shared may be re-disclosed by the recipient and may no longer be protected by federal privacy rules.

I have read and understand my rights *

Yes

Signature

Signature — type your full legal name *

Parent or guardian name, if client is a minor

Date signed *

What a valid ROI form must include

Who discloses and who receives
Exactly what may be shared
The purpose of sharing
An expiration date
The right to revoke
Treatment doesn't depend on signing
Signature and date

What's included

Client full name
Client date of birth
Name of person or organization
Their role
Their phone, fax, or email
Direction of the exchange
Information to be shared
Anything specific to include or exclude
Purpose of the exchange
This authorization expires on
I have read and understand my rights
Signature — type your full legal name
Parent or guardian name, if client is a minor
Date signed

Prefer paper? Print it

Download this form as a PDF or Word file — free, no account. When you're ready, send the same form as a link so nobody retypes a clipboard.

This template is a starting point, not legal or medical advice, and using it does not by itself make your practice HIPAA compliant. To collect patient health information on TendForm, use the HIPAA plan with a signed Business Associate Agreement, and have your own counsel review consent and policy wording.