Authorization, Consent & Release of Information

Lake County Care Collective · Complete the form below, select your providers, then print or save as PDF.
!
Instructions
Please print out a copy of the Release of Information form, fill out your name and information, select all LCCC providers who are treating you, select the most appropriate box for the information allowed to be discussed, and sign. Once completed, please email a copy to each provider you’ve selected.
Section 1 — Client Information
Section 2 — Authorize Release Between Providers

I hereby authorize the release of information between the providers I select below. Check all providers you authorize to discuss your care.

✓ 0 providers selected
Section 3 — Scope of Release

Or specify below: e.g. information about risk, how many sessions I attended, general prognosis, diagnosis, treatment recommendations, etc.

Or describe your own purpose below:

Section 4 — Expiration & Signature
I understand that I can revoke this request and authorization at any time. I also understand that this authorization expires one year from today's date unless otherwise indicated below.
Sign on the printed copy