CONFIDENTIALITY

The law protects the privacy of all communications between a patient and a therapist. In most situations, if you are 18 years of age or older, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA and Illinois law. However, there are several situations in which no authorization is required.  Examples are listed below.

Consultation with other health or mental health professionals
Teaching and supervision
Malpractice suits or complaints
Judicial and administrative proceedings (e.g., if you are involved in court proceedings)
Workman’s Compensations claims
Government/Health Agency oversight
Health Insurer payment or collection on overdue fees

Therapists are mandated reporters.  As such, there are some situations in which I am legally obligated to take actions in order to protect you and others from harm.  If these circumstances arise in the course of your treatment, I may be required to reveal information about you or your treatment without your specific authorization.  If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.

Exceptions to confidentiality:

If I have reasonable cause to believe that a child under 18 known to me in my professional capacity may be an abused child or a neglected child, the law requires that I report this to the local office of the Department of Children and Family Services.

If I have reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months, the law requires that I report this to the agency designated to receive such reports.

If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you, such as friends or the police.

If you have made a specific threat of violence against another or if I believe that you present a clear, imminent risk of serious physical harm to another, I may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking your hospitalization.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you have now or arise in the future. The laws governing confidentiality can be complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.

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Pagone Psychological Services Release of Information


Review Privacy Policy

Pagone Psychological Services, PLLC at Whispering White Horse Stables, LLC

Authorization for Release of Information (2022)

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, LPC (Pagone Psychological Services, PLLC, and Whispering White Horse Stables, LLC) to release or obtain (check all that apply):

I Agree
Obtain written or electronic medical or clinical records from a previous provider                   

I Agree
Exchange verbal information         

I Agree
Release clinical chart (excluding psychotherapy notes) 

I Agree
Release billing records                                           

I Agree
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, LPC to release or obtain this information for the following reasons (check all that apply):

I Agree
At the request of the client                                     
I Agree
Payment or insurance purposes

I Agree
For consistency in treatment                                  
I Agree
Social support assessment  

I Agree
For treatment planning and implementation           
I Agree
Other: ____________________________

 

Length of authorization (Choose only ONE):

I Agree
This authorization shall remain in effect until __________ (usually one year from today’s date). 

I Agree
This authorization shall remain in effect indefinitely throughout my treatment with Jenn Pagone, LCPC, LPC until rescinded by signing below.

I Agree
Information may be released only on the day the authorization form is received.

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 understand that I have the right to revoke this authorization at any time in writing to Jenn Pagone, LCPC, LPC. 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 Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
I certify that I am 18 years of age or older
First Clients Information
Click to customize question*
No
Yes
First Clients Signature*
Second Clients Name

First Name*

Last Name*

Phone*
Second Clients Date of Birth*
Second Clients Information
Click to customize question*
No
Yes
Second Clients Signature*
Third Clients Name

First Name*

Last Name*

Phone*
Third Clients Date of Birth*
Third Clients Information
Click to customize question*
No
Yes
Third Clients Signature*
Fourth Clients Name

First Name*

Last Name*

Phone*
Fourth Clients Date of Birth*
Fourth Clients Information
Click to customize question*
No
Yes
Fourth Clients Signature*
Fifth Clients Name

First Name*

Last Name*

Phone*
Fifth Clients Date of Birth*
Fifth Clients Information
Click to customize question*
No
Yes
Fifth Clients Signature*
Sixth Clients Name

First Name*

Last Name*

Phone*
Sixth Clients Date of Birth*
Sixth Clients Information
Click to customize question*
No
Yes
Sixth Clients Signature*
Seventh Clients Name

First Name*

Last Name*

Phone*
Seventh Clients Date of Birth*
Seventh Clients Information
Click to customize question*
No
Yes
Seventh Clients Signature*
Eighth Clients Name

First Name*

Last Name*

Phone*
Eighth Clients Date of Birth*
Eighth Clients Information
Click to customize question*
No
Yes
Eighth Clients Signature*
Ninth Clients Name

First Name*

Last Name*

Phone*
Ninth Clients Date of Birth*
Ninth Clients Information
Click to customize question*
No
Yes
Ninth Clients Signature*
Tenth Clients Name

First Name*

Last Name*

Phone*
Tenth Clients Date of Birth*
Tenth Clients Information
Click to customize question*
No
Yes
Tenth Clients Signature*
Clients 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*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Name of Person and/or Organization
Phone, Fax, Email, and Address of Person and/or Organization
Reason For Release:
For the Purpose of:
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.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Click to customize question*
No
Yes
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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