Communication Release Form

A communication release form lets you give written permission for Integrative Mental Health of the Midwest to share any private information with specific people or organizations for specific reasons.

• It explains exactly what information can be shared (for example, treatment details or records).

• It names who your provider is allowed to talk to (such as another provider, a family member, or an agency).

• It helps maintain your privacy through HIPAA rules while helping coordinate care or services or communication.

• If you are a parent of a teen over the age of 13, your teen will be asked to sign the form in order for the provider to be able to share certain information with you. For more information see the National Center for Youth Law’s detailed explanation here.

Upload your insurance information here.