Attached is the Authorized Release of Information Form required for all clients during the referral submission stage.
This form was updated in March of 2022 to ensure that the ROI covers all required exchanges of information for successful care coordination between DBHDD providers across the state, especially in support of the GHVP Housing Support Program.
The form also allows sharing the identified information with the Balance of State Continuum of Care administered by the Department of Community Affairs as well as the eight local Continuums of Care.
The form also allows an individual to authorize the release of information related to substance use and HIV status in order to help identify all available housing resources for which someone may be eligible, as well as to properly coordinate supports and care. Under the law, provider agencies must have the authorizing individual's initials next to each category of information to allow for it to be shared.
The authorization for information sharing remains in effect as long as is necessary or earlier if it is revoked. Therefore it does not need to be renewed annually.
This form is a fillable PDF. Individuals may sign digitally by typing their name into the form. Providers may not sign on behalf of individuals.