Authorization/Release of Information

Authorization/Release of Information
I Name of Client* , whose birthdate is: Date* .
Authorize name of PeoplePsych employee* of PeoplePsych, LLC to disclose to and/or obtain the following information from Name of Person or Title of Person or Name of Organization*
Description of Information to be Disclosed (Patient/Client check each item to be disclosed)*

AssessmentCurrent Treatment UpdateDischarge/Transfer SummaryDiagnosisMedication Management InformationContinuing Care PlanPsychosocial EvaluationPresence/Participation in TreatmentProgress in TreatmentPsychological EvaluationNursing/Medical InformationDemographic InformationPsychiatric EvaluationToxicological Reports/Drug ScreensTreatment Plan or SummaryEducational Information
PURPOSE: The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services. If other purpose, please specify:
REVOCATION: I understand that I have a right to revoke this authorization at any time by notifying PeoplePsych 111 N Wabash, No. 1203, Chicago, IL 60602. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.
EXPIRATION:

Unless sooner revoked, this consent expires on the following date: Date or as otherwise indicated: if applicable - please enter reason If a calendar date is not recorded to terminate permission to release, this authorization expires one year after date signed.
CONDITIONS: I further understand that therapist name will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences:
FORM OF DISCLOSURE: Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.
REDISCLOSURE: State and Federal law prohibit the person or organization to whom disclosure is made from making any further disclosure of this information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by Federal and State laws.
I understand that I have the right to inspect and copy the information to be disclosed. I will be given a copy of this authorization for my records.
Signature of Patient/Client*

Clear
Date*

MonthDayYear
Date
Signature of Parent, Guardian or Persona Representative

Clear
Relationship to Client
Date

MonthDayYear
Date
Should be Empty:

Authorization/Release of Information

EXPIRATION: