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Jenn Pagone, LCPC

Release of Information

Pagone Psychological Services, PLLC

Authorization for Release of Information (2025)

This form authorizes the release of protected information from your clinical record to the person(s) or agency you designate.

I,

the undersigned, hereby authorize and request Jenn Pagone, LCPC (Pagone Psychological Services, PLLC) to release or obtain (please read the below options and type that information in the section below):

  • Written or electronic medical or clinical records from a previous provider                  
  • Exchange verbal information         
  • Release clinical chart (excluding psychotherapy notes) 
  • Release billing records                                         
  • Write a letter on my behalf

Unless a written request has been received regarding a specific mode of transmission the following modalities may be utilized to disclose the permitted information: verbal, electronic, paper format (hard copy), or facsimile. I understand that I have the right to review and copy the disclosed mental health information at any time.

I am requesting Jenn Pagone, LCPC, to release or obtain this information for the following reasons (please indicate this in the section below):

  • At my (the client's) request                                 
  • Payment or insurance purposes
  • For consistency in treatment                             
  • Social support assessment  
  • For treatment planning and implementation        
  • Other: Please Indicate Below

Length of authorization (Choose only ONE and indicate below):

  • This authorization shall remain in effect until [text] (usually one year from today’s date). 
  • This authorization shall remain in effect indefinitely throughout my treatment with Jenn Pagone, LCPC until rescinded by signing below.
  • Information may be released only on the day the authorization form is received.

I Agree
I understand that Illinois and Wisconsin law prohibits redisclosure of any information disclosed to the recipient pursuant to this authorization unless this authorization specifically permits such redisclosure. I further understand that if information is released to a party in another state, redisclosure may be allowable according to their state laws. I also understand that once my therapist releases information, she has no responsibility or control over how that information is stored or utilized.

*************************************************************************************

I Agree
I understand that I have the right to revoke this authorization at any time in writing to Jenn Pagone, LCPC. However, revocation will not be effective to the extent that information has already been released based on this authorization, or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

First Client's Name

First Name*

Last Name*

Phone*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Signature*
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Signature*
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Signature*
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Signature*
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Signature*
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Signature*
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Signature*
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Signature*
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Signature*
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Name of Person and/or Organization

Name of Person or Organization *
Recipient Information

Phone *

Fax and/or Email *

Address of the Individual or Organization *

What information is to be obtained or released *

Length of Authorization *
Reason For Release:

Reasons for Release or any other information you would like to provide.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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