Release of Information (ROI) Form
The Counseling Center staff cannot disclose/share your Protected Health Information (PHI) without your prior consent. If you would like copies of your counseling records, or would like information from your records shared with another party, you must first submit a completed ROI (below).
The Release of Information (ROI) does not provide blanket coverage for all of your visits at the Counseling Center throughout your time at Dartmouth. When submitting the completed ROI, please include information about the intent of the ROI and how much of your records you would like disclosed (i.e., information to coordinate continuity of care, all therapy notes, all medication management notes, all mental health notes, etc.). At any time you are welcome to call the Counseling Center to discuss your records with a provider.
IMPORTANT: The ROI expires one year from the date you sign the ROI, unless you specify a different date under letter "a".
The completed ROI can be faxed to (603) 646-9506 (ATTN: Counseling Center) or emailed to the Counseling Center.
**Please allow up to 10 business days for processing.