Skip to main content

Release of Information (ROI)

The Counseling & Human Development (CHD) staff cannot disclose/share your Protected Health Information (PHI) without your prior consent. If you would like copies of your CHD records or you would like information shared with someone else you must first submit a completed ROI (below):

RELEASE OF INFORMATION (ROI)/AUTHORIZATION

The completed ROI can be faxed to (603) 646-9410 (ATTN: CHD) or emailed to CHD@Dartmouth.edu.
NOTE: We do require the originally signed document. Please mail the original ROI to: CHD, 7 Rope Ferry Road, Hanover, NH 03755.

Guidelines to help you complete this form:

Section #1 of the ROI: Check off the information you would you like released.

  • Counseling treatment records: If checked, all clinical counseling session notes, DP2 (athletics) consultation records, and eating disorder treatment 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.
  • Dick's House inpatient counseling records: If checked, all records related to your mental health inpatient stay at Dick's House will be released to the designee in Section #2. NOTE: If you stayed in inpatient for a medical reason these records WILL NOT be released by CHD.

Section #2 of the ROI: Check off who you are releasing your PHI (Protected Health Information) to as well as how (mail, phone or fax). Due to confidentiality and security reasons we elect not to email PHI.

  • Fill in designee 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. However, if there are more than 20 pages we will mail the records in place of faxing.

Section #3 of the ROI: 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 of the ROI: 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.

Contact the CHD office with any questions, (603) 646-9442.

Last Updated: 6/27/17