PDBTI Release of Information (ROI) Form

PDBTI clients or their legal guardians may use the secure electronic form below to sign a Release of Information (ROI). Typically clients are asked to sign an ROI for coordination of care with other healthcare providers, agencies, or people involved in your care. They may also be used to request or send health records between listed agencies or individuals.
If you are unsure how to fill out an ROI for your situation or request, we recommend you first speak with your PDBTI therapist or a support staff member. We also have an example of a completed ROI form, please click HERE. Note that if we do not get all the necessary information or signatures on your submitted ROI, we may ask you to sign a new one.

Please review and fill in all appropriate fields on the secure form below. After you finish and “sign” to submit, you will have the option to immediately download a copy for your records. You will also be asked to enter an email address where you would like a confirmation email to be sent, which will include a link to access and re-download the completed form (up to 30 days). Make sure to only enter an email address if you are okay with the account users potentially accessing your completed PDBTI form!

If you do not have an email address, or if you prefer not to include one for privacy reasons, please enter the following placeholder email address: none@pdbti.org
If you use the placeholder email, a copy of the completed form will only be sent to PDBTI support staff for processing. You will still have the chance to download a copy of the form if you like on the submission confirmation page.

If you prefer to print and fill out an ROI form by hand instead, please visit our Client Forms page for printable versions.

If you run into any issues or need technical support, please contact our Portland front desk at (503) 231-7854 extension 0 or our Salem front desk at (503) 231-7854 extension 8, or your PDBTI therapist.