Release of Information Form

RELEASE OF RECORDS
Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Hereby REQUEST and AUTHORIZE Decatur Psychological Associates, P.C. to release/obtain the following information pertaining to my Substance Abuse and/or Mental Illness:
Check all that Apply*
- Select All
- Medical History
- Diagnosis & Prognosis
- Social History
- Psychiatric History
- Psychological History
- Treatment Plan
- Summary
- Laboratory Results
- X-Ray Reports
- Operative Notes
- Progress Reports
- Financial History
- Substance Use History
- Legal History
- Mental Health Assessment
- Personal History
- Educational History
- Other (Specify Below)
Other (please specifiy)
Release to / obtain from:
Name of Physician, Health Care Facility, Agency Etc.
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
The above information for the following period of time shall be released:
Date Format: MM slash DD slash YYYY

From
Date Format: MM slash DD slash YYYY

To
This information is being disclosed from records whose confidentiality is protected by one of the following state or federal laws. State law and federal regulation (42CFR part 2) and mental health and developmental disabilities confidentiality act (ILL. Rev Sate 1991. ch91 1/2 Par 801 ct seq.) which prohibits the redisclosure of any general authorization for the release of medical or other information is not sufficient for this purpose. I understand that I have the right to inspect and receive copy of the information that is disclosed.I understand that I can revoke this consent in writing at any time except as to disclosures already made. Unless revoked, this consent to release will expire on year from the date signed on...
Today's Date*
Date Format: MM slash DD slash YYYY
This is a continuing disclosure which covers the entire treatment episode and until all claims are filed and processed.

I attest to the Identity of Signatory (is) below:
Guardian Signature
Initials
Date
Date Format: MM slash DD slash YYYY
Patient Signature*
If the Patient is 13 years or older they MUST also sign the consent
Initials

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Release of Information Form

RELEASE OF RECORDS