Name: Tompkins & Associates
Address: 1801 N. Mill Street Suite C, Naperville, Illinois, 60563, US

Authorization for Release of Confidential Information

I authorize:

Tompkins and Associates
1801 N. Mill Street, Suite C
Naperville, IL 60563
630-717-5911
and...*
Client Name*
First Last
Date of Birth*
MM slash DD slash YYYY
The information is being exchanged for the consultative purpose of*
- Sharing diagnostic information
- Sharing treatment information
- Sharing results of clinical assessment
- Sharing report of Psychological Assessment
- Sharing recommendations based on current clinical care
I further give my consent for this communication to be by e-mail*
Initial
The consent is valid until*
- 6 Months
- 1 Year
- 2 Years
The statutes that govern this authorization include but are not limited to:

Mental Health and Developmental Disabilities Confidentiality Act (740ILCS110), 735 ILCS 5/8-2001 (inspection and copying of hospital records), and any relevant confidentiality code of any state, and the Employee Personnel Records Act, 820 ILCS 40/0.01
I understand that I have the right to revoke this consent in writing at any time and that I have the right to copy and inspect the information being disclosed.
Signature of Client or Legal Guardian*
Date
Signature of Minor Child (Age 12 Years or Older)*
Date
Signature of Witness*
Date
Notice to Receiving Agency/Facility/Person: Under the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, (740 ILCS 110/1) you may not redisclose any of this information unless the person who consented to this disclosure specifically consents to such redisclosure. Under Federal Act of July 1, 1975, Confidentiality of Alcohol and Drug Abuse Patient Records, no such records, or information from such records may be further disclosed without specific authorizations for such redisclosure.
Phone
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