AIC Associates

VM:       (847) 604-1932

Office:   (847) 543-8378

Fax:       (847) 543-9424

Susan R. Smith, Ph.D.

Licensed Clinical Psychologist

205 Commerce Drive

Suite C

Grayslake, IL 60030                                                                  

AUTHORIZATION FORM

THIS FORM WHEN COMPLETED AND SIGNED BY YOU, AUTHORIZES ME TO RELEASE PROTECTED INFORMATION FROM YOUR CLINICAL RECORD TO THE PERSON/COMPANY YOU DESIGNATE.

I authorize my psychologist, _____________________________and her administrative staff to release/exchange the following information: 

____ Diagnostic Assessment ____ Discharge Plan ____ Progress Notes ____ Treatment Plan ____ Treatment Summary

____ Psychological Test Reports ____ Medical Evaluation ____ Nutritional Assessment ____ Psychiatric Evaluation ____ Other

This information should only be released to (name and address of person/company to whom the information is to be released) ____________________________________________________________________________________________

____________________________________________________________________________________________

I am requesting my psychologist to release this information for the following reasons:  (“at the request of the individual” is all that is required if you are my patient and you do not desire to state a specific purpose.)
_____________________________________________________________________________________

This authorization shall remain in effect until (fill in expiration date) _____________________      If no calendar date is stated, information may be released only on the day the authorization form is received the psychologist.

You have the right to revoke this authorization, in writing, at any time by sending such written notification to my office address.  However, your revocation will not be effective to the extent that I have taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I understand that my psychologist generally may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party. 

I understand I have the right to inspect the disclosed mental health information at any time.

I understand that Illinois law prohibits re-disclosure of any information disclosed to the recipient pursuant to this authorization unless this authorization specifically authorizes such re-disclosure.

______________________________                          _________________

Signature of Patient                                                             Date

_______________________________                        __________________

Signature of Parent/ Guardian                                            Date

If the authorization is signed by a personal representative of the patient, a description of such representative's authority to act for the patient must be provided.