Authorization To Disclose/release Protected Health Information Form
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1Authorization to Disclose/Release Protected Health Information
(Must be signed by patient or legal representative before medical records will be released)
Patient Name: ____________________________ Date of Birth: _______________ Phone: _____________
Address: __________________________________ City/State: __________________ Zip Code: __________
I authorize Illinois Bone and Joint Institute Medical Records Department to use/disclose a copy of the specified
protected health information as indicated below to (Recipient):
Recipient: Name:___________________________ Phone: __________________ Fax: ___________________
Address: _________________________________ City: ________________ State: _____ Zip Code: _______
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Send the entire medical record (all information) to the above named recipient.
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Send only the following information to the above named recipient: ________________________________
__________________________________________________________________________________________
Records for the period (dates) from: ____________________ to _____________________________________
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Purpose or need for information:
Continuation of care
Personal use
Other/Describe: _____________
I understand that if this information is emailed per my request, there may be some level of risk that this
information could be read by an unauthorized third party.
I must check one or more of the following types of health information that I do NOT want released to the above
recipient. I understand that if I do NOT check any of the four (4) boxes below, the health information released to
the Recipient may include:
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HIV/AIDS related information/records
Genetic testing information/records
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Mental health information/records
Drug/alcohol diagnosis, treatment or referral
I understand that if the person or entity that receives the above information is not a healthcare provider or health
entity covered by federal privacy regulations, the information described above may be re-disclosed and no
longer protected by these regulations. However, the recipient may be prohibited from disclosing substance
abuse information under the Federal Substance Abuse Confidentiality Requirements.
I understand that I may refuse to sign this authorization and that my refusal will in no way affect my ability to
obtain treatment or payment or my eligibility for benefits. I may inspect or receive a copy of any information
used/disclosed under this authorization.
I understand that I may revoke this authorization at any time, provided that I do so in writing, except in the
instance that action has already been taken in reliance upon this authorization. Unless revoked earlier, this
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expires in 30 days
authorization:
is a 1-time request
expires in ________ days.
Unless otherwise specified, this form expires one year from date of signature.
Signature of Patient or Patient’s Legal Representative: ______________________________ Date: _________
Print Name of Legal Representative: ______________________________ Relationship: __________________
Form-Authoriz to Release PHI rev 7-14
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Parent category: Medical