Release of Information

I hereby authorize SpringSource Psychological Center, PLLC to release to and obtain information from: (this should be someone like a medical doctor/psychiatrist/dietitian or emergency contact, etc.)

Name:

Phone:

Address:

Relationship:

For the purposes of further mental health evaluation and treatment, and/or Coordination of Care between providers, the following information will be communicated: Intake and Discharge SummariesMedical History and EvaluationConfirmation of AdmissionTreatment PlanDiagnosisSummary of Course of TreatmentTreatment for Substance Use if ApplicableEmergency ContactOther

I have had explained to me and fully understand this request/authorization to release/obtain records and information, including the nature of the records, their contents, and the likely consequences and implications of their release. This request is entirely voluntary on my part. I understand that I may take back this consent at any time, except to the extent that action based on this consent has already been taken.

Client Name:

This entry acts as a client signature.

Date:

Questions? Call Us Now!
224-202-6260
Location
53 W. Jackson Boulevard, Suite 520
Chicago IL 60604

Serving Cook County, IL and the following cities: Chicago, Elgin, Cicero, Schaumburg, Evanston, Arlington Heights, Palatine, Skokie, Des Plaines, Orland Park, Glenview

Susan Foti McClanahan, Ph.D.
DrMcClanahan@SpringSourceCenter.com
Angela Derrick, Ph.D.
DrDerrick@SpringSourceCenter.com
Our Commitment To Diversity
Insurances Accepted
We are in-network for Blue Cross Blue Shield PP0, Blue Choice, Aetna, Cigna, and Optum/United