Release of Information

Release of Information

Walking Together Therapy Associates, P.C.
I, First Name* Last Name*, D.O.B. Date*, Hereby Authorize: * to release any and all records to and/or to obtain information from:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Specific nature of information to be disclosed:

Other
For the purpose of (please check all that apply)

Other
This consent is valid until

MonthDayYear
Date
I understand that I have the right to inspect and copy the information to be disclosed and may revoke this authorization at any time by submitting a written and dated notice of revocation. Any such revocation will not affect materials disclosed prior to the revocation. I also understand that Walking Together Therapy Associates, P.C. or any of its employees therefore cannot be held liable for any disclosures prior to the date of such revocation. The above named person authorized to receive this information may use the information only for the purposed outlined above and may not redisclose it without my written authorization.
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, HIPAA, 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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