Forms

Need to complete paperwork? Select the form below that best fits your request.

Release of Information (ROI) Authorization Form

A Release of Information (ROI) authorizes MindDivers to communicate with or disclose protected health information to a specific individual or organization that you designate.

Use this form if you are giving MindDivers permission to share information.

Examples:

• Authorizing us to speak with a parent, spouse, or other family member.
• Authorizing us to communicate with your attorney.
• Authorizing another person or organization to receive information about your care.
  

Request of Records (ROR) Authorization Form

A Request of Records (ROR) is used to request copies of your medical records from MindDivers.

Use this form if you are requesting copies of your records.

Examples:

• Requesting a copy of your medical record for your personal files.
• Requesting records to be sent to another healthcare provider.
• Requesting records for legal, school, or insurance purposes.

Fee: Requests for copies of your own medical records are subject to a flat processing fee of $6.50, as permitted by California law. Payment instructions will be provided once your request is received.

Not sure which form you need? Contact our office and our team will be happy to help determine which form is appropriate for your request.

This keeps the distinction clear:

• ROI = Permission to share information.
• ROR = Request for copies of records.

Once complete, please send it to staff@minddivers.com. Thank you!