Release of Information for Emergency Contact

Patient Name*
Patient Date of Birth*
MM slash DD slash YYYY
Name of Light on Anxiety Therapist*
As the individual receiving Cognitive Behavioral Therapy (CBT) at Light on Anxiety or Parent or Guardian of Recipient or other person entitled to inspect and copy Recipient’s records pursuant to 740 ILCS 100/4 or, as applicable 42 CFR 2.31 and/or 20 ILCS 301/1-1), I hereby authorize Light On Anxiety to disclose and/or obtain information from my mental health records to the following party (please provide name and contact information for party):
Name of Emergency Contact for LOA to Exchange Information With*
Prefix First Last
Email Address
Phone Number*
Fax Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
The purpose of this disclosure is for the following:*
Other:
The specific nature of the information to be disclosed is as follows:*
- Any information related to securing the safety of the client
- Other (please specify below)
Other:
Advanced Consent to Release Information*
I hereby acknowledge and agree to Advanced Consent of the release of information detailed in the prior question.
Acknowledgement of right to inspect all information disclosed:*
I understand and acknowledge that I have the right to inspect and copy any and all information such being disclosed pursuant to this Consent.
Acknowledgement of potential consequences of a refusal to consent to release of records:*
I understand and acknowledge potential consequences of a refusal to consent to release of records, for example, Light on Anxiety no longer providing therapy or if a third party (not an insurance company) requires these records to pay for therapy, a consequence may be that the therapy will not be paid for.
Acknowledgement of Right to Revoke Consent*
I understand and acknowledge that I have the right to revoke this Consent at any time. I further understand that any Revocation of this Consent shall be in writing, signed by me or the person who gave the Consent and the signature on the Revocation of the Consent shall be witnessed by a person who can attest to my identity or the identity of the person who signed this Consent and is entitled to sign the Revocation of this Consent. I further understand that no Revocation of this Consent is effective to prevent disclosures of records and communications until it is received by Light on Anxiety. The Revocation of this Consent shall have no effect on disclosures made prior to receipt by Light on Anxiety of the Revocation of Consent.
Re-disclosure of Information*
I have been made aware that no information disclosed by Light on Anxiety may be redisclosed without my specific consent to redisclose.
Copy of Consent Will Be Stored in Patient Record*
I understand and acknowledge that a copy of this Consent and a notation as to any action taken thereon shall be entered in my record.
This Advanced Consent will expire on the date below:*
MM slash DD slash YYYY

Note: It is recommended to select a date one year from today.
Name of Signee (Recipient of Services at Light on Anxiety or Parent or Guardian of Recipient of Services at Light on Anxiety)
Signature of Recipient or Parent or Guardian of Recipient or other person entitled to inspect and copy Recipient’s records pursuant to 740 ILCS 110/4 (and/or 42 C.F.R. 2.31).*
Date Consent Signed On:*
MM slash DD slash YYYY
Witness attestation to signing of this consent:*
I hereby attest to the identity and that I witnessed the individual receiving Cognitive Behavioral Therapy (CBT) at Light on Anxiety or Parent or Guardian of Recipient or other person entitled to inspect and copy Recipient’s records sign this Consent for the Disclosure of Mental Health Records and Communications.
Name of Witness to Signing of This Consent
Signature of Witness to Signing of this Consent*
Date Consent Signed On*
MM slash DD slash YYYY
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The purpose of this disclosure is for the following:
- Coordinate care and share relevant clinical information on treatment plan, treatment goals and progress to date
- Send copy of Light on Anxiety record to external party indicated on release
- Obtain copy of record from external party indicated on release

Release of Information - Emergency Contact

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