ROI - Release and Revoke of Information Request
Client Page

ROI-Release of Information Form

Revocation of Release of Information (pg. 3)

What is a ROI Form

There are three pages on the same form:

Release of Information Consent Form
Targeted Release Form
Revocation of Release of Information Form

These forms determine what client information Counseling Professionals PLLC and its providers can release to a specific third party provider, not billing, but for a coordination of care. Further Description in Video and Below.

How to use ROI Form

Step by Step Process

Click on the Link to the form above
Enter the Client/Guardian Email to start the ROI Form Signing
Enter the Client's Counseling Professionals PLLC Provider Email
Client Opens their email to sign the form
Client enters Required Information and Options based on situation:
Client name
- Party to receive information, phone , and email
- What information is to be release and how
- Signature
Provider Receives the signed form automatically in their email
Provider signs and executes the Release of Information

Description of Each Page of ROI and its use (Note: All on same form)

Release of Information Consent

A release of information consent form is a legal document authorizing a specific entity to disclose an individual's confidential information to a designated recipient, typically for medical, educational, or employment purposes.

Targeted Release Request

A targeted release of information consent form is a legal document that specifies and limits the scope of information to be disclosed, authorizing the release of only certain pieces of an individual's confidential information to a designated recipient.

Revocation of Release of Information

A revocation of release of information form is a legal document that withdraws a previously granted authorization, effectively halting the disclosure of an individual's confidential information to a designated recipient.

Dual Custody or Two Guardian Process

Step 1

Provider submits a separate request for ROI to both Guardians

Step 2

Guardian 1 and Guardian 2 will receive separate ROI and Sign

Step 3

Provider verifies agreement or works to reconcile disagreement under company or supervisor review

Step 4

Once verified, ROI or Revocation is executed to the coordination of care outlined in Signed ROI

For any other individual cases, please consult with your Counseling Professionals PLLC provider or CaseyKenny@CounselingProfessionalsPLLC.com with any questions specific to your situation. QR to form below as option.

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ROI - Release and Revoke of Information Request Client Page