I do hereby consent and authorize Thrive Mental Health Services to release all information contained in my financial and medical records, including diagnoses and test results, to my insurance company or health plan, their agents and independent contractors, or any other person or entity that is responsible for paying or processing for payment any portion of my bill, for the purposes of administration, billing and quality and risk management. This consent applies to all records created in the course of and relating to my treatment and for the purpose of reimbursement for treatment.

I understand that I may revoke this consent at any time by giving written notice to the Thrive Psychiatry and Wellness except to the extent that action has been taken in reliance thereon. If no prior notice of revocation is received, this consent will expire six (6) months after the date of patient discharge from treatment, unless another date or condition is specified.

I understand that if I refuse to consent to this Release of Information, the consequences will be that the insurance claim will not be filed.