Release of Information (ROI) Authorization

Use this form to authorize Imperial Foundation Community Development Center (IFCDC) to release, receive, or exchange your information.

Client Name: ________________________________

Date of Birth: ________________________________

Address: ____________________________________________

I authorize IFCDC – Imperial Foundation Community Development Center to:

☐ Release Information    ☐ Receive Information    ☐ Exchange Information

To/From: ____________________________________________

Purpose: ____________________________________________

Information to be shared (check all that apply):

☐ Mental health records

☐ Medical information

☐ Assessments / evaluations

☐ Progress notes summary

☐ Case management notes

☐ Other: _____________________________

Expiration Date: ________________________________

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken based on this authorization.

Client/Guardian Signature: ____________________ Date: __________

Witness/Staff: ____________________ Date: __________

Executive Director Approval

This authorization is not valid without approval from: Mr. Fahreal Allah – Owner & Executive Director.

Executive Director Signature: ____________________ Date: __________

To submit this form, please print, complete, and return it to IFCDC at 1215 Springwood Ave Suite 28, Asbury Park, NJ 07712, or contact us at (732) 743-5048 / service@ifcdc.org.