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.
Mental Health Program ROI Form
This ROI form is used specifically for our Mental Health program to securely and safely exchange your health information between Herself Health and other external parties/providers that you may see. This form is optional and is not a requirement for your participation in the program, but it does give us permission to smoothly continue your mental health care to ensure your Herself Health team is communicating with your other providers to keep you feeling your best.
If you desire, please fill out this form completely and sign and date it. Please bring this form in at your next appointment.
How To Reach Us
If you have any questions, we are happy to help!
We are available via phone 24/7. Please call us at 1-888-290-1209 with any questions. Calls made to this number outside our scheduled business hours will be connected to an after-hours on-call service staffed by registered nurses