Clone of Release of Information

AUTHORIZATION FOR RELEASE AND/OR EXCHANGE OF INFORMATION
I, First and Last Name* Date of Birth*,

Hereby authorize: Patrick J. Kennelly, Ph.D. and Associates, P.C. to transfer my records to: Walking Together Therapy Associates, P.C.
Andrea Benn, Ph.D., M.Ed.Sandi Corbett, MA, LCPCScott M. Cyphers, LCPCCarole Dankers, L.C.P.C.Patrick J. Kennelly, MA, MS, Ph.D.Ray S. Kim, Ph.D.Antoinette Krakowski, PsyDRobert Lasica, LCSWMaria Matusiewicz, MA, LCPCTerry Neary, Ph.D., CADCPei Yu, Ed.S., LCPC
Signature of Minor Recipient, 12-17yrs. Inclusive
Signature of Adult Patient or Parent*
Date*

MonthDayYear
Date
NOTICE TO PATIENT AND RECEIVING AGENCY

Under the provision of the Illinois Mental Health and Development Disabilities Confidentiality Act, HIPPA, and applicable Federal and State Alcohol and Substance Abuse Confidentiality Acts, there may not be redisclosure of any of the information provided pursuant to this release unless the patient, and/or parent of the patient who is a minor, specifically authorizes such disclosure. A separate release is required for psychotherapy notes.
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