About this template
This Mental Health Release of Information (ROI) form is designed for clinical practices, therapists, and mental health facilities to standardize how they obtain patient authorization. It provides a clear, professional framework for patients to specify exactly which information can be shared, with whom, and for what purpose, ensuring that the provider remains compliant with privacy standards while facilitating effective care coordination.
By using this Doc2Form template, providers can move away from cumbersome paper-based workflows. The form captures essential details, including the authorized party's contact information, the specific scope of the disclosure, and the duration of the consent. This structured approach helps reduce administrative errors and ensures that all necessary legal permissions are documented before any sensitive health data is released to third parties, such as primary care physicians, insurance providers, or family members.
Key features
- Capture clear patient authorization for specific health data.
- Define explicit timeframes for information disclosure.
- Collect contact details for both receiving and disclosing parties.
- Mobile-friendly design for easy completion in-office or remotely.
- Standardized fields to ensure consistent documentation.
Use cases
- Coordinating care between a therapist and a primary care physician.
- Releasing records to insurance companies for billing verification.
- Sharing progress updates with legal representatives or family members.
- Transferring patient history to a new mental health provider.
What this form collects
- Patient Full Name (Short answer)Enter your full legal name.
- Date of Birth (Date)Format: MM/DD/YYYY
- Authorized Party Name (Short answer)The name of the individual or organization you are authorizing to receive your information.
- Authorized Party Contact Information (Paragraph)Provide the address, phone number, or fax number of the authorized party.
- Purpose of Disclosure (Paragraph)Why is this information being shared? (e.g., treatment planning, insurance, legal)
- Information to be Disclosed (Paragraph)Specify the records or information you authorize to be released.
- Authorization Expiration (Multiple choice)When should this authorization expire?
- Patient Signature (Short answer)Please type your full name here to serve as your digital signature.
- Date Signed (Date)Today's date.
FAQ
Is this form template customizable?
Yes. Once you import this template into your Google Drive, you can add, remove, or modify any fields to match your specific clinical requirements.
Can patients fill this out on their phones?
Yes, Google Forms are inherently mobile-responsive, allowing patients to review and sign the document from any smartphone or tablet.
How do I ensure the data is secure?
Google Forms data is encrypted in transit and at rest. Ensure your Google Workspace account is configured with the appropriate security settings for handling sensitive health information.
Can I export these responses for my records?
Yes, all submissions are automatically saved to a linked Google Sheet, making it easy to archive or export the data for your patient files.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.