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A bright blue sky with a single white cloud drifting into the bottom right corner of the frame, cut off at the edge for a sense of open space and forward motion, representing the straightforward and accessible process of sharing information through Availia TeleHelp PLLC's Release of Information page.

Blank ROI

Required for disclosure and/or any communication, confirmation or denial of engagement history regarding certain, confidential services, an 'ROI' or 'Release of Information,' authorizes such releases.

When and Why

Complete an ROI any time you need Availia to communicate with someone outside this agency about your services.

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Common reasons to complete an ROI, depending on the service type:

 

  • You are authorizing a urinalysis lab to send results directly to Availia or for Availia to contact the lab directly about you and your lab results 

  • Your attorney or legal representative needs updates on your services

  • A court, probation officer, or case manager needs information about your services

  • Your employer needs documentation of your participation

  • You are transferring to or from another provider

  • A family member or emergency contact has your permission to communicate with Availia on your behalf (and/or vice versa)
     

Availia Client Information:

Date of Birth
Month
Day
Year

Authorized Entity:

Authorization Details:

I authorize the mutual release, exchange, & confirmation of my personal, clinical, & otherwise confidential information between the above parties, using any reasonable and secure method. The purpose of this disclosure may include service coordination, compliance reporting, and other uses permitted by law. Information may include service details, clinical notes, progress notes, attendance, completion and discharge status, urinalysis results, and compliance details. Any information that has been disclosed from records protected by federal confidentiality rules (42 CFR Part 2) is prohibited from any further disclosure unless expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is not sufficient for this use. This authorization expires one year from the date of last disclosure or external correspondence made under this authorization.

Client Acknowledgment

Availia TeleHelp PLLC and signee agree that any digital signature may serve the full legal effect and function of a handwritten signature.

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