ROI - Release and Revoke of Information Request
Client Page

Pro Side ROI

The video to the right shows what the Provider's responsibility is for completing the ROI and making sure that it gets uploaded and executed to the Medical record system. Provider has four steps:

What is a ROI Form

There are three pages on the same 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.

Client Side ROI Form

Step by Step Process

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.