ROI - Release and Revoke of Information Request
Client Page
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 us 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.
