Youth First Name *
Youth Last Name *
Youth Birth Date *
Is the youth under 13 years of age? * Yes No ROI MUST be signed by youth if 13 years old, orLEGAL guardian if 12 or under.
Guardian First Name *
Guardian Last Name *
Guardian Birth Date *
Youth or Guardian Email *
Youth or Guardian Address *
Guardian or Youth Address (line 2)
Guardian or Youth City *
Guardian or Youth Zip Code *
County * Select County...
Island
San Juan
Skagit
Snohomish
Whatcom
To communicate with and disclose to one another the following information *
(Check all that apply)
Initial and subsequent evaluations of service needs by Community Collaboration and members Current and past Mental Health Treatment Programs, with dates Current and past Substance Use Disorder Treatment Programs, with dates Current and past Emergency Department visits, with dates Past or present Mental Health Problems or Diagnosis Past or present Substance Use Disorder Problems or Diagnosis Past or present Physical Health Problems Past or present Physical Health Problemse Other* Enter if other selected *
We need to decide what we want the following disclaimer text to be in the ROI?
When I am asked to fill out this authorization, I am entitled to a copy.
I have the right to revoke this authorization at any time. Any revocation will not take effect if action has already been taken based on the original authorization. Without my express revocation, this authorization will expire in one year from the signature date below.
The information disclosed and redisclosed may contain information on my current/past: Mental Health, substance or alcohol use, and/or HIV status, and I authorize the disclosure and redisclosure for the purposes of this authorization.
The information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by, with the exception of, Substance Use Disorder records which are protected by federal regulations that prohibit the recipient from making any further disclosure of this information unless further disclosure is expressly permitted by my consent or as otherwise permitted by 42 CFR part 2.
I understand that this authorization is voluntary and that I may refuse to sign this form. My refusal to sign will not affect the treatment or services I receive from specific providers but will limit the ability of the workgroup members to discuss my needs and to coordinate my care.
Signature of Individual or representative able to authorize:
E-Signature
Sign in the area below and click Accept to generate your signature.
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