Authorization for Release of Patient Health Information

Child & Adolescent Health Associates, LTD

Please correct the errors described below.

I hereby authorize the protected health information regarding the above-named person be forwarded

From

Person/Institution: Child and Adolescent Health Associates
Address: 1030 N Clark St, 4th floor
City/State/Zip: Chicago, IL, 60610
Phone: 312-943-6964
Fax: 312-943-6924

I authorize the release of information covering the period(s) of healthcare from

If not otherwise specified this release will expire within 30 days of the date of signature.

I understand that Child and Adolescent Health Associates may, directly or indirectly, receive remuneration from a third party in connection with the use and disclosure of my health information. I understand that I have the right to inspect and obtain a copy of any information about mental health, drug and alcohol, or developmental disability services that is disclosed pursuant to this Authorization. I have read and understand the terms of this Authorization and I have had the opportunity to ask questions about the use and disclosure of my health information. By my signature, I hereby, knowingly and voluntarily authorize Child and Adolescent Health Associates to use or disclose my health information in the manner described above.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

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