This release of information is for other AGENCIES or PROVIDERS that you would like involved in your mental health care.
This release is ONLY good for ONE YEAR, unless you contact Northland Counseling Center, Inc and state you would like to revoke an ROI. Without your permission, Northland Counseling Center, Inc cannot release information to other parties. We can release information without a release if there are Mandated, Vulnerable Adult, or Duty to Warn reports.
When filling out this form, please fill it out to the best of your ability and fill in all the required fields. This is NOT mandatory and only needed if you would like to have information requested or provided to other agencies or providers.
If you are receiving medication management services, you will be asked to fill out Release of Information forms for your pharmacy, medical clinic and, if applicable, previous medication provider to name a few.
This form is ONLY valid with a signature.
Release of Information for Other Agencies
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