Authorization for Release of Information

Name of Client
Name of Client
Recipient of mental health services
Date of Birth
Date of Birth
Authorization
I, (The Client), do hereby authorize Dr. James D. Wellman to release AND exchange information from the clinical record regarding my protected health information to:
Name
Name
Person, Health Care Provider, Facility, or etc.
Address
Address
Phone
Phone
For the Purposes of
Please check all that apply
1 - Verbal Release and Exchange
Information to be released and exchanged includes the following: (Please check all that apply for VERBAL and WRITTEN Release and Exchange)
2 - Written Release and Exchange
Information to be released and exchanged includes the following: (Please check all that apply for VERBAL and WRITTEN Release and Exchange)
Valid From
Valid From
Today's Date
To
To
Usually One Year Later
Authorization Consent
I understand that I have the right to rescind this authorization at any time by sending WRITTEN notice to Dr. James D. Wellman 3660 North Lake Shore Drive, Suite 210 Chicago, Illinois 60613 I understand that a withdrawal of this release is not valid to the extent that Dr. James D. Wellman has acted in confidence on such authorization.
Name *
Name
(12 Year or Older) Your Social Security Number will act as Signature of Authorization
Date *
Date
Parent or Guardian
Parent or Guardian
Your Social Security Number will act as Signature of Authorization
Date
Date
Witness *
Witness
Your Social Security Number will act as Signature of Authorization
Date
Date