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ROI - NJ Release of Confidential Information

LifeBack
4 Princess Road Suite 206
Lawrenceville, New Jersey 08648
Phone 609-482-3701
Fax 609-482-3702
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
* I authorize LifeBack to disclose information to and/or obtain information from:     Include the name of the recipient and/or agency where applicable.
* Phone #
* Fax, email, or other contact information    If not applicable write "N/A or None"
* I approve the following information to be released or obtained:
Patient's Presence/Participation in Treatment  Progress and Prognosis   Counseling Assessment 
Psychiatric Evaluation  Treatment Plan/Treatment Goals  Diagnosis 
Medication and Medical Information  Discharge Summary/Continuing Care Plan   Scheduling 
Medication Refills  Other 
* The purpose for the disclosure of this information is to:
Coordinate care with other treatment provider(s)   Coordinate with parent(s)/guardian(s)  Satisfy employment requirements 
Satisfy school requirements   Satisfy legal requirements   Other 
  
* Expiration: Unless sooner revoked, this authorization is effective on the date signed below and expires on    NOTE: expiration date cannot exceed 365 days after date of signature.
* Electronic Signature    I understand that by typing my name below and clicking "Submit," I am electronically signing this document.
* Relationship to Patient    If you are signing as a parent, guardian, or personal representative of the Patient, please indicate relationship or authority. TYPE N/A IF NOT APPLICABLE
* Date
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