Herself Health Patient Forms

Authorization to Receive Records

This ROI form is used to securely and safely exchange your health information between Herself Health and other external parties/providers that you may see. With your permission, this will allow us to smoothly continue your care to ensure us, your Herself Health team, is communicating with your other providers to keep you healthy.

Please fill out this form completely and sign and date it. Please bring this form in at your next appointment.