Authorization For Release Of Medical Information Form


Number ___________________
Name of Patient: ________________________________________________________ Date of Birth: ____________________
Number to call (_____) ______ - ________ Call when ready? (circle) yes no
(Circle) Email Fax Mail
Date of Request: _________________
Date Needed: ___________________
Number to fax (_____) _____-___________
I authorize the use or disclosure of the above named individual’s health information, its employees and agents, to furnish:
Blessing Hospital
Blessing Physician Services
Name: __________________________________________________
Blessing Walk-In
Illini Community Hospital
Address: _________________________________________________
c/o Health Information Management
Telephone: _____________________ Fax: ______________________
Telephone: 217-223-8400 x 6600 Fax: 217-214-5890
The type of information to be used or disclosed is as follows (check all of the appropriate boxes and details as needed):
Dates of Service/Treatment (include specific dates or date range):
Continuing Care Abstract (includes all Physician dictation & Radiology, Lab and Cardiology reports)
Discharge Summary
Laboratory and Pathology Reports
Mental Health Records
History and Physical
Cardiology Reports (EKG, ECHO, Cath, etc)
Psychological Testing
X-ray Reports
Clinic Notes (Wound, Pain)
Operative Reports
X-ray Films
Itemized Bill
Emergency Department Records
Therapy Notes (PT, ST, OT, Radiation, etc)
Entire Record for dates listed
Other (please specify): ______________________________________________________________________________
Office Notes
Immunization Records
Entire Record for dates of service
Laboratory Reports
Physical Forms
Workability or School Release forms
Itemized Bill
Mental Health Records
Other (please specify): ________________________________________________
I understand that the information in my health record may include information relating to sexually transmitted disease, genetic testing, acquired
immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services
even though I am protected by Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patients Records, 42 CFR Part 2, the Illinois AIDS
Confidentiality Act, or the Mental Health and Developmental Disabilities Confidentiality Act. A request in writing must be made to exclude the above from
the disclosed information.
I understand photo identification may be required to obtain medical records.
The purpose for which this disclosure is being made is:
My personal records
Sharing with other healthcare providers
Other (please describe) __________________________________________________________________________
I understand that I have the right to revoke this Authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present
my written revocation to the Health Information Management Department. I understand that the revocation will not apply to information that has already
been released in response to this authorization.
I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy
laws or regulations. In accordance with the Mental Health Code – No person or agency to whom any information is disclosed may re-disclose such
information unless the person who consented to the disclosure specifically consents to such re-disclosure. I understand that I have the right to inspect and
copy the information that is to be disclosed.
This Authorization expires on: __________________________________. If I fail to specify an expiration date, this authorization will expire six months from
date of signature.
I understand authorizing the use or disclosure of the information identified above is voluntary. Healthcare treatment, payment, enrollment in the health plan,
or eligibility for benefits is not conditioned on signing the authorization. Beyond this, my refusal to consent may have the following consequence – failure to
disclose information. Electronic images/records (ie Radiology) on CD/USB media are not encrypted or password-protected and are the sole responsibility of
the recipient of the records to protect from unauthorized viewing. Unencrypted CD/USB media cannot be mailed by Blessing.
_____________________________ ______________
_____________________________________ ____________
Signature of Patient or Legal Representative
_____________________________ _______________
Legal Representative Relationship (POA) __________________
Minor Age 12 to 17
This Authorization must be signed by the patient or guardian if patient is less than 12. In keeping with the Mental Health & Services Disability
Confidentiality Act, if the patient is a minor and recipient is 12 years of age or older, then this authorization must be signed by the patient. If the patient is
mentally incompetent and over the age of 18, this Authorization must be signed by the appointed legal representative of the patient.
Revised 8/2015


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