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).