TCA Counseling Group
6 Edgerly Place. Suite 3 . Boston MA 02116 . 617.861.0370(t) . 617.249.1937(f)
Two-Way Release of Information
Your Name
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First Name
Last Name
Your Email
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example@example.com
Your Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Phone Number
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Your DOB
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Month
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Day
Year
Date
Please check.
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I authorize TCA Counseling Group at 6 Edgerly Place, 3rd Floor, 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.
Please give the name of the person you would like us to contact.
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First Name
Last Name
What is the address for this person?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the phone number?
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Who is your therapist?
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Tell us what information we can release to the above person.
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Entire records
Psychotherapy notes
Progress notes
Admissions documentation
Assessments
Attendance
Discharge summary
Treatment plan
Consult notes
What is the purpose for the information?
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Care coordination
Facilitate billing
Referral
Obtain insurance, financial or other benefits
Other
Please check that you understand this information.
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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.
This authorization will expire on the below date or, if nothing is specified, it will expire when I am no longer receiving services from TCA Counseling Group.
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Month
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Day
Year
Date
Patient or Guardian's Signature
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Today's Date
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Month
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Day
Year
Date
Submit
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