Get Template Roi Consent Form For Non-part 2 Providers 2-7-18.docx

Filling out the ROI Consent Form for Non-Part 2 Providers online is an essential step for individuals wishing to share their behavioral health and substance use treatment information. This guide will help you navigate the process clearly and effectively, ensuring that all necessary information is completed correctly.

Follow the steps to fill out the form accurately and securely.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
2. In the first section, fill in the legal last name, first name, any other names used, middle initial, date of birth, individual ID number, and patient address. This information identifies the patient whose consent is being documented.
3. Next, you will find Section A where you specify the organizations that are authorized to disclose your information. List each organization, including all relevant details.
4. In Section B, indicate the specific organization that is authorized to receive the disclosed information. Ensure that you provide the full name of the entity.
5. Section C requires you to consent to the disclosure of all behavioral health and substance use disorder treatment information. Check the boxes for the purposes applicable to your circumstances: treatment, care management, and/or quality improvement.
6. Complete Section D by providing the expiration date for the consent, noting that the default term is one year unless a different duration is specified.
7. In Section E, review the statements regarding your understanding of the consent form. While filling this out, ensure that you acknowledge and understand each point.
8. Finally, provide your signature or the signature of your legal representative, if applicable. Include the date and phone number, and if a legal representative signs, specify their name and relationship to the patient.
9. Once all sections are thoroughly completed, save the document. You may download, print, or share the form as required.

Complete your documents online today to ensure your healthcare needs are met.