I the parent or legal guardian authorize The Rock Counseling Group to disclose and obtain from the individual or organization listed below:
Address of Persons or organization:
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 the
Expiration: Unless sooner revoked, this authorization expires 365 days from the date completed or as otherwise indicated:
Forms 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.