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Wellman Psychology – Expert Psychotherapy Services in Chicago, IL
Home
About
Our Way
Our Team
Our Office
Staff
Psychotherapy
Evaluations
LGBTQ+
Blog
Schedule Today
Forms
Developmental Questionnaire
Release Authorization
Informed Consent - Dr. Wellman
Payment Authorization
Contact Authorization
Authorization for Release of Information
Name of Client
Recipient of mental health services
First Name
Last Name
Date of Birth
MM
DD
YYYY
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
Person, Health Care Provider, Facility, or etc.
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
For the Purposes of
Please check all that apply
Treatment and Follow-Up
Coordination of Care
Psychological Evaluation
Other (specified)
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)
Social
Medical
Psychological
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)
Social
Medical
Psychological
Valid From
Today's Date
MM
DD
YYYY
To
Usually One Year Later
MM
DD
YYYY
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
*
First Name
Last Name
Digital Signature
*
(12 Year or Older) Your Social Security Number will act as Signature of Authorization
Date
*
MM
DD
YYYY
Parent or Guardian
First Name
Last Name
Digital Signature
Your Social Security Number will act as Signature of Authorization
Date
MM
DD
YYYY
Witness
*
First Name
Last Name
Digital Signature
*
Your Social Security Number will act as Signature of Authorization
Date
MM
DD
YYYY
Thank You for Authorizing the Release of your Information.