Allen's Family Counseling Center RELEASE OF INFORMATION

Allen's Family Counseling Center RELEASE OF INFORMATION

226 W Ontario St. Ste 400C, IL 60654 www.afccchicago.com (312) 912-7008
I, _______ First Name Last Name ________________________, Date of Birth Date and currently residing at Street Address Address Line 2 City State Zip _____, do hereby authorize ALLEN'S FAMILY COUNSELING CENTER__, with the address located at 226 W. Ontario St. STE 400C CHICAGO, IL 60654__to release my medical records to:
First Name Last Name Street Address Address Line 2 City State Zip Email Area Code Phone Number Company/Agency
The information to be released shall be for and limited to the purposes of:

LEGAL USE (Attorneys, Courts, Law Enforcement, Federal Government etc..)MEDICAL (PCP, Care Coordination, Insurance, Referral, etc..)ASSISTANCE (Social Worker, Case Worker, Assistance Programs)CARE GIVER (Spouse, Parent, Child, Other Family, Friends, Power of Attorney)EDUCATIONAL INSTITUTIONS (Schools, IEP/504 Teams, School Counselors, etc.)EMPLOYMENT / HR PURPOSES (EAP, Fitness for Duty, Return-to-Work Evaluations, etc.)SELF / PERSONAL USE (Copy for Client or Guardian)Other
Information to Be Released: (Check all that apply)

Treatment SummaryDiagnosisProgress NotesMedication ListAttendance VerificationBilling / Payment HistoryOther: __________________________ALL REQUIRED
Purpose of Release:

Continuity of CareLegal / Court RequirementInsurance / PaymentClient RequestOther
This authorization will expire on: ___ Date ___ (date)

If no date is specified, this authorization will expire one year from the signature date.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken based on this release. I understand that once my information is disclosed, it may be subject to redisclosure by the recipient and may no longer be protected under HIPAA. This authorization does not permit the recipient to authorize the release of my information to a third party without my written consent.
Patient Name

First NameLast Name
Date

MonthDayYear
Date
Patient Email
example@example.com
Patient Signature

Powered by Jotform SignClear
Should be Empty: