Release of Information Form
For healthcare providers referring a client to LIFT.
Who Needs to Complete This Form?
If you’re a licensed healthcare provider referring a client to LIFT, you are required to complete this Release of Information (ROI) form. This gives us legal permission to receive and review the client’s protected health information so we can coordinate appropriate care.
If you’re not a healthcare provider (e.g., a probation officer, first responder, family member, or community agency), you do not need this form. Please return to the Referral Page to continue.
Release of Information Form
Once you submit this form, you’ll receive an email with the agreement that you will need to sign.