I Authorization For Disclosure of Mental Health Treatment Information
authorize The Rock Counseling Group to
disclose to and obtain from the individual or organization listed below:
Address of Persons or organization information is being released to:
Purpose: This information may be used or disclosed in connection with mental health treatment, treatment coordination, or payment for services rendered. If the purpose is other than as specified, please provide additional information:
Revocation: I understand that I have a right to revoke this authorization, in writing, at any time by sending a written notification to The Rock Counseling Group at 201 West Springfield Ave, Suite 1201 Champaign, IL 61820 attention: medical records. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on th e
Expiration: Unless sooner revoked, this authorization expires 365 days from the date completed. If you would like this release to end prior to 365 days please identify the date you would like to this release to expire. Cannot exceed 365 days for date of completion
Forms of Disclosure: Unless you have specifically requested in writing that the disclosure be made in a certain for mat, 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.