Authorization to Release Health Care Information

First Name(Required)

Last Name(Required)

Date of Birth(Required)

West County Psychological Associates (1215 Fern Ridge Parkway, Suite 110, St. Louis, MO 63141) has my permission to exchange health care info. with:

Name(Required)

First Last

School/Organization:

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

WCPA may exchange the following information:

Health care information relating to the following treatment or condition:

Health care information for date(s):

All health care information

Other

Please explain any other related information:(Required)

Please add dates:(Required)

Please add any other information:(Required)

Purpose: The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment, and when appropriate, to coordinate services.

Other purpose as applicable:

This authorization ends:(Required)

on this date:

or when the following occurs:

Date(Required)

Please explain(Required)

I understand that WCPA will not condition my treatment on whether I sign this authorization form.

I may cancel this authorization in writing as allowed by law. This would not affect any actions already taken based upon my original request. There are three ways to cancel this authorization: 1) Sign and date a revocation form. This form is available from WCPA; or 2) Write, sign and date a letter to WCPA to cancel the authorization; or 3) Sign, date and write “CANCEL” on this original form.

I understand that once WCPA gives out information, WCPA has no control over it. The recipient might re-disclose it. Privacy laws may no longer protect it.

I understand that I am agreeing to the exchange of health care information regarding testing, diagnosis, and/or treatment for psychiatric disorders, mental health and/or drug and/or alcohol use.

Consent(Required)

I fully understand and agree to the above stated terms.

Date(Required)

First and Last Name of Patient or Legally Authorized Individual(Required)

Relationship to patient(Required)

if signed on behalf of the patient by parent, legal guardian, personal representative, etc.