ROI Authorization- English 2026

1. Click ‘Get Form’ to open the ROI Authorization- English in the editor.
2. Begin by clearly printing the Member’s Name, CIS #, AHCCCS #, and Date of Birth in the designated fields.
3. Identify the person or agency authorized to make the disclosure. In this case, it is Touchstone Health Services, along with their address.
4. Fill in the details of the person or agency receiving the information. Ensure you include their name, phone number, address, email, and fax number.
5. Select your preferred release method by checking one of the options: Mail, Pick-Up, Fax, or E-Mail.
6. Indicate which information you wish to disclose by checking all applicable boxes related to assessments and records.
7. Specify any other information to include and provide dates for records if necessary. If no dates are provided, a two-year release will be assumed.
8. Sign and date the form at the bottom. If applicable, ensure that any required signatures are also included.

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