I authorize TCA Counseling Group at 262 Beacon Street, Suite 3, Boston 02116 to receive and release information from or to the person, agency or facility named below, either verbally or in writing, as indicated in this authorization.

Entire records Psychotherapy notes Progress notes Admissions documentation Assessments Attendance Discharge summary Treatment plan Consult notes

Care coordination Facilitate billing Referral Obtain insurance, financial or other benefits Other

I understand that I have a right to revoke this authorization at anytime. If I revoke this authorization, I must do so in writing and present it to TCA Counseling Group at the address identified on this page. I understand that the revocation will not apply to information that has already been released pursuant to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. I understand that once the above information is disclosed to a person, facility or agency outside from Tonn Q. Cao, the recipient may re-disclose it and the information may not be protected by federal or state privacy laws or regulations. I understand that authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to receive treatment or services from TCA Counseling Group. However, lack of ability to share or obtain information may prevent its clinicians, and/or the other named person, facility or agency, from providing appropriate and necessary care.