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


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.

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