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.

 

ROI Instructions

Section 1: Fill in your name, date of birth, contact phone number, and graduation year

Section 2: Select the information you would like disclosed:

  • Counseling treatment records: If checked, all clinical counseling session notes and DP2 (athletics) consultation records will be released to the designee in Section #3.
  • Medication management records: If checked, all session notes related to medication prescription management will be released to the designee in Section #3.
  • 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, Community Standards and Accountability Office, 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 #3.

Section 3: Select to whom are releasing your Protected Health Information (PHI):

  • If you would like records released to yourself, parents/other family, or an outside treatment provider, fill in the recipient's name, address, phone number, and fax number.
  • IMPORTANT: During the COVID-19 pandemic, counseling records will be faxed or emailed to the recipient. Please include a legible fax or email on the ROI.

Section 4: Indicate 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'.

Signature and Date Signed

  • Please be sure to sign and date the ROI (electronic signature is acceptable). 

Fax the completed ROI to (603) 646-9506, or email to Counseling@Dartmouth.edu. Please allow up to 2 weeks for processing.

Please contact the Counseling Center at (603) 646-9442 with any questions.