Authorization For Disclosure of Mental Health Treatment Information

Authorization For Disclosure of Mental Health Treatment Information
Full Legal Name of Client

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:
Birthdate of Client (MM/DD/YYY)
Client Street Address
Client City and State of Residence
Client Zip Code
Name of person or organization information is being obtained or released to
Phone Number of person or organization information is being released to
Address of Persons or organization information is being released to:
Street Address
City
State
Zip code
What information are your authorizing to be disclosed or obtained?

Demographic InformationIntake AssessmentPsychotherapy NotesPresence and Participation in TreatmentAppointment Times and AttendancePsychosocial AssessmentTreatment Progress and SummaryPayments, Invoices, ReceiptsDiagnosis OnlyTreatment PlanContinuation of Care PlanOther
If Other Please Explain:
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:
Other Reason
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
Expiration of Release Date Preferred

MonthDayYear
Date
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.
Signature of client over 12 years or legal guardian

Clear
Date

MonthDayYear
Date
Signature of Parent or Guardian if client under 12 Years

Clear
Date

MonthDayYear
Date
Witness Signature

Clear
Date

MonthDayYear
Date
Should be Empty: