Release of Information (ROI)

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 in the gray section at the bottom of the ROI.

Release of Information (ROI)

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

**Please allow up to 10 business days for processing.
 

1. Fill in your name, date of birth, contact phone number, and Dartmouth Net ID.

2. Select the purpose of the disclosure.

3. Check off the information you would like released to the recipient:

• Counseling treatment records: If checked, all clinical counseling session notes and DP2 (athletics) consultation records will be released to the recipient.
• Medication management records: If checked, all clinical notes related to medication prescription management will be released to the recipient.
• Information needed to coordinate academic consideration: If checked, information directly related to the academic consideration will be shared with the recipient.
• Information needed to coordinate time away & return for medical reasons: If checked, information directly related to a students' request for time away or return from time away will be shared with the recipient.
• Nutrition Wellness Team coordination of care: If checked, you are giving permission for the Health Service Nutrition Wellness Team to coordinate care with your home/community provider(s).
• Other: Use this space when requesting a specific piece of information from your record. Only this information will be shared with the recipient. For example, "ADHD diagnosis records only".

4. Select the recipient of the information being released.

• 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.

5. Authorization Expiration Date: It is only necessary to fill in a date here if you want the ROI to expire on a specific date. Otherwise, the ROI will expire from the 'Date Signed'.

6. Signature and Date Signed: Please be sure to sign and date the ROI (electronic signature is acceptable). 

Fax the completed ROI to (603) 646-9530, 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.