Release of Information

Light On Anxiety values collaborative care with other providers as it helps to create the most integrated and appropriate treatment plan. Please note: If you are using your insurance benefits for Light On Anxiety services, we will attempt to obtain reimbursement for this collaborative care service from your insurance company. If insurance does not reimburse, you will be charged at a prorated private pay rate. We attempt to keep all collaborative care exchanges as quick and effective as possible, typically about 20 minutes.

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 110/4 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):