The following programs are authorized to:

X disclose X receive information as noted below:

 Whitehall CAP Inc. (WCAP Counseling)
Authorized Individual/Organization to Authorized to Make Disclosure

Change Healthcare, and Covering Insurance Agency
Authorized Individual/Organization to Whom Disclosure is Made

Purpose of Disclosure: To facilitate billing for services

Type of Information to be Disclosed:

___progress notes,  ___diagnostic assessment information, ___progress in treatment, ___lab results, ___urine screen results, ___ attendance, _X__diagnosis, _X__information on mental illness and/or treatment,  __X_ other information (specify):  Treatment dates and duration

Amount of Information to be Disclosed:

I authorize the release of any information necessary to process claims with my insurance company and I authorize my insurance company to make payments for my treatment directly to Whitehall CAP Inc.(WCAP Counseling).