Type of information that may be shared or disclosed: Summary of Entry Papers; Summary of Termination; Treatment Dates, Goals and Progress, Educational and Labor History; Development and/or Social History; Medical history; Psychological Evaluation, another;
Purpose: At the request of the individual; Additional Mental/Psychological/Psychiatric Health Assessment; Treatment and Additional Care; Treatment Planning and/or Coordination; Research.
AGENCY/RECIPIENT NOTICE: Federal and State law prohibits the person or organization from whom information is being shared from making any further disclosure of such information unless this is explicitly permitted by written authorization from the person concerned or as permitted by 42 C.F.R. Part 2 or the Illinois Mental Health and Developmental Disabilities Confidentiality Act (740 ILCA 110/1 et. seq.)
I understand that I have the right to revoke this authorization in writing at any time by sending written notice to the therapist designated above. However, the revocation of this will not be effective to the extent that action has been taken under the previously authorized or if this authorization has been obtained as a condition of obtaining insurance coverage and the insurer has the legal right to contest a claim. If no notice of revocation is received, it will automatically expire on this date: (one year after you have signed it; if left blank the form is valid only for the day the authorization form was received by the therapist).
I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notice to the Therapist designated above. However, your revocation will not be effective to the extent that I have taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
If no prior notice of revocation is received, this will automatically expire on this date: _________________(one year from date signed; if left blank, valid only the day the authorization form is received by the therapist)
I understand that The Genesis Therapy Center generally may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party. However, failure to sign this authorization may have the following consequences: