Return of Information - Elena Kaiser

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Therapy Services
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Intake Forms

Request of Information Form

this form is going to be used to grant the release patient information.

Patient Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone number*
Date of Birth*
DD slash MM slash YYYY
Authorization FOR Release/ exchange of highly confidential health information. ( evaluation, diagnoses, mental health care)
I hereby authorize*
Elena Kaiser
From:*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
To:
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Purpose or Need for information*
Disclosure will include the following checkboxes.*
- Face Sheet
- History & Physical
- Laboratory/ Diagnostic Testing Results
- School Information
- Discharge Summary
- Medication Records
- Behavior Health/ Psychological consult
- psycological Evaluation/Testing Results
- ER Recrod Report
- Psychiatric Evaluation
- Psycological Assesment /therapy
- Summary of Treatment Records
- Legal Information
- HIV Test Results
- ED Report Record
- Other
Record dates from:
MM slash DD slash YYYY
To:
DD slash MM slash YYYY
I have the right to inspect and copy the health information to be released and if I do not sign this Authorization, the institution named above the information. The above-named person/institution will not refuse to treat me based on whether I agree to allow my health information to others. I also understand that this Authorizationnis subject to revocation/ withdrawal by me at any time in writing to the medical record contact except to the extent that action has already been taken to release this information. This authorization shall remain valid unless revoked.
Expiration Date:*
MM slash DD slash YYYY

This release is valid for one (1) year from the date signed unless I fill in an early date.
Signature*

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Address: 2530 Crawford Ave, Suite 305
Evanston, Illinois 60201

Request of Information Form

Call Us: 847-337-2377

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