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3040 N. University Ave., Suite 2 Decatur, IL 62526 217-872-1700
Decatur Psychological Associates, P.C.
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    • Registration & Consent Forms
    • Release of Information Form
  • Home
  • Staff
  • Fee Schedule
  • Forms
    • Registration & Consent Forms
    • Release of Information Form

Release of Information Form

  • RELEASE OF RECORDS

  • MM slash DD slash YYYY
  • Hereby REQUEST and AUTHORIZE Decatur Psychological Associates, P.C. to release/obtain the following information pertaining to my Substance Abuse and/or Mental Illness:
  • Release to / obtain from:
  • MM slash DD slash YYYY
    From
  • 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...
  • 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:
  • MM slash DD slash YYYY
  • If the Patient is 13 years or older they MUST also sign the consent
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