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
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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