IMPORTANT—PLEASE READ BEFORE COMPLETING THIS FORM
ONE FORM IS NOT ENOUGH.
A separate Authorization to Release Information (ROI) must be completed for every provider, school, agency, facility, program, or other record holder connected to each parent and each child involved in the case.
This means:
One ROI for each provider or organization;
Separate ROIs for each parent and each child; and
Separate ROIs when the same provider has records for more than one family member.
For example, if one therapist treated both a parent and a child, two separate ROIs must be completed—one for the parent and one for the child.
You may need to complete approximately 5–10 or more forms for your family. Submitting one ROI does not authorize all providers to release information.
Please complete an ROI for all applicable current and former:
Therapists, psychologists, psychiatrists, and mental-health facilities;
Physicians, pediatricians, hospitals, specialists, and other medical providers;
Schools, daycares, educational programs, and children’s service providers;
Substance-use evaluators, treatment programs, and testing facilities;
DCF/CPS, law-enforcement, probation, and other government agencies;
Parenting coordinators, guardians ad litem, prior evaluators, supervised-visitation providers, and other court-related professionals; and
Any other provider, agency, program, or organization that has evaluated, treated, counseled, educated, supervised, or provided services to a parent or child.
REQUIRED PROVIDER CONTACT INFORMATION
You are responsible for providing the correct contact information for every provider or organization listed.
Each ROI must include at least one working method for sending the request:
Our office will not research provider fax numbers, email addresses, or other missing contact information. Contact the provider directly before completing the ROI and confirm where record requests should be sent.
An ROI that does not include a working fax number or email address will not be processed or used.
Because approximately 5–10 or more ROIs may be submitted for each family, our office cannot individually contact parties regarding missing or incorrect provider information. You will not receive a separate reminder or notification that an incomplete ROI could not be used.
It is your responsibility to make sure every ROI is complete and contains accurate provider contact information before submitting it.
HOW TO COMPLETE EACH FORM
Person/Parent Authorizing Release
Enter the information for the person who is giving permission and signing the form.
If you are authorizing the release of your own records, enter your information.
If you are authorizing the release of your child’s records, enter your information as the parent or legal guardian.
The date of birth, telephone number, and email address in this section must belong to the person signing the authorization.
Ward/Child Information
Enter the full legal name and date of birth of the person whose records are being requested.
If you are releasing your own records, enter your name again and identify the relationship as “Self.”
If you are releasing your child’s records, enter the child’s information and identify your relationship—for example, “Mother,” “Father,” or “Legal Guardian.”
Case Name and Number
Enter the complete court case name and case number exactly as they appear on your court documents.
Example: Smith v. Smith, Case No. 16-2026-DR-000000
Outside Provider or Organization Releasing the Records
This section is for the outside provider, school, agency, facility, program, or organization that currently maintains the records.
DO NOT enter Dr. Tracy Riley or Tracy Riley Counseling in this section.
Before completing the form, contact the provider and obtain:
The provider’s complete name;
The name of the records department, records custodian, or contact person;
A working fax number or email address where the ROI should be sent;
The provider’s telephone number; and
The provider’s complete mailing address.
Do not guess. Do not enter your own telephone number, fax number, email address, or mailing address in place of the provider’s information.
Type of Provider
Select the option that best describes the provider or organization. If you select “Other,” identify the type of provider in the space provided.
Records Authorized for Release
Select “Complete File” if the provider is authorized to release the entire record. Otherwise, select every category of information that may be released.
The authorization also permits the provider to communicate directly with Dr. Riley regarding the records and relevant information.
Signature and Submission
The person authorizing the release must:
Sign electronically or type their full legal name in the signature field;
Enter the same name in the “Printed Name” field;
Enter the date;
Complete the security verification; and
Select “Submit.”
After submitting one ROI, return to this page and complete another form for every additional provider, school, agency, facility, program, or record holder.
Review each form carefully before submitting it. Make sure all names are spelled correctly, all required fields are completed, and a working fax number or email address has been provided.
Dr. Riley’s receiving-provider information is already included at the bottom of the form. You do not need to enter it anywhere else.