Consent to Treatment

I have hereby been informed that my therapist will be asked to provide clinical evaluation and treatment information to my insurance company. I further understand that this information is confidential and may not be disclosed or released to anyone other than authorized insurance company staff without my written authorization. The exceptions are (listed below):

• 1. Information necessary to authorize services or pay claims will be communicated to the safe keeper/claims payer when required.
• 2. If I disclose information during the course of treatment or evaluation which indicated I may present a clear and present danger to myself and others.
• 3. As mandated by law.