To protect your confidentiality and comply with HIPAA laws, if you would like our clinic to communicate with anyone, including, but not limited to, a family member, a caregiver, a trusted friend, therapist, and/or a medical professional, please sign this form, have a witness sign it, and send it back to us via the Patient Portal. Without this signed ROI, we cannot confirm or deny that you are our patient and neither can we communicate with anyone about you without your consent, unless it is an imminent safety concern to you and others. If you are under a legally appointed guardian for your medical and psychiatric care, you must first provide us with a copy of the order granting the guardianship or any other court appointment.