Release of Information (ROI)

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):

Release of Information (ROI)

The completed ROI can be faxed to (603) 646-9506 (ATTN: Counseling Center) or emailed to the Counseling Center.

*At this time we do not accept electronic signatures. Please print the ROI, fill it out and sign it, then scan and email or fax to the Counseling Center.

Guidelines to Complete ROI Authorization Form

Section 1: Check off the information you would like to have disclosed.

  • Counseling treatment records: If checked, all clinical counseling session notes and DP2 (athletics) consultation records will be released to the designee in Section #2.
  • Medication management records: If checked, all session notes related to medication prescription management will be released to the designee in Section #2.
  • Information needed to coordinate academic consideration: If checked, treatment information can be relayed to campus offices such as: Student Accessibility Services, Academic Skills Center, Deans Office, Judicial Affairs, etc.
  • Eating Disorder Team coordination of care: If checked, you are giving permission for the Dick's House Eating Disorder Team to coordinate care with your home/community provider(s).
  • Nutrition treatment records: If checked, all nutrition session notes will be released to the designee in Section #2.

Section 2: Check off to whom you are releasing your Protected Health Information (PHI).

  • Fill in the recipient’s name, address, phone number, and fax number if we are releasing records to yourself, parents/other family, or an outside treatment provider.
  • We will fax records when a fax number is indicated. Records will be mailed if there are more than 20 pages being released. PHI cannot be emailed at this time.

Section 3: Check off the purpose of the disclosure.

Authorization Expiration Date: If an expiration date is not indicated the ROI will expire one year from the 'date signed'.

Section 4: If applicable, initial in the appropriate blank authorizing disclosure of Alcohol or Drug Treatment Records and HIV Status.

Signature and Date Signed

  • Please be sure to sign and date the ROI. Please also fill in your contact phone number, date of birth and graduation year.

Please allow up to 2 weeks for processing. Please contact the Counseling Center at (603) 646-9442 with any questions.