Medical Release of Information Form

This form authorizes the release of your medical information to specified parties. Please complete all required fields.

Patient Information

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

From:

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

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.