Authorization For Release Of Information
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1Authorization for Release of Information
Patient Name __________________________________________________________________ DOB __________________________
Address _____________________________________________________________________________________________________
City ____________________________________________________________ State __________ Zip ________________________
Phone (best daytime number)_____________________________________________________________________
I hereby authorize ____________________________________________________________________________________________
to release information from my medical record as indicated below to:
Person/Institution/Other _______________________________________________________________________________________
Address _____________________________________________________________________________________________________
City ____________________________________________________________ State __________ Zip ________________________
Phone _________________________________________________ Fax _________________________________________________
I authorize the release of information pertaining to the following time periods:
All date(s) ________
OR
From date(s) _____________________ To Date(s) _____________________
INFORMATION TO BE RELEASED:
ALL Records
Clinic/Office Records
Diagnostic Reports (lab, xray,etc)
Operative Reports
Physical Therapy
X-Ray/MRI images/films
Other _______________________________
The following highly CONFIDENTIAL items must be checked off to be included in the disclosure:
HIV/AIDS related health information/records
Drug/alcohol diagnosis, treatment, referral information
Behavioral or mental health information/records
Genetic testing information/records
This authorization expires (date):_________________. If not specified, this release will expire 1 year after the date of signature.
٠I understand that I have the right to inspect and copy the information I have authorized to be disclosed by this authorization. In the
event I refuse to authorize the release of the above-described information, I understand that it will not be disclosed, except as
provided by law.
٠I understand that the practice may not condition treatment on whether I sign this authorization, except when the provision of
health care is solely for the purpose of creating protected health information for disclosure to a third party.
٠I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and
may no longer be protected by law.
٠I understand that this authorization is valid until it expires, unless revoked before that.
٠I understand that I may revoke this authorization at any time by giving written notice to the physician of my desire to do so. I also
understand that I will not be able to revoke this authorization in cases where the physician has already relied on it to use or
disclosure my health information. Written revocation must be sent to the physician’s office.
٠I have read and understood the terms of this Authorization and I have had the opportunity to ask questions about the use and
disclosure of my health information. By my signature, I knowingly and voluntarily authorize the entity identified above to use or disclose my
health information in the manner described above.
٠I understand that in compliance with the Illinois State Law Statute, I will pay a fee according to said statute based on page count of records to be
copied. There is no charge for medical records of two year history if copies are sent to facilities/provider for ongoing care. Records older than
two years are subject to fees according to Illinois State Law.
Printed name of patient, legal guardian, or authorized agent: __________________________________________________________
Signature of patient, legal guardian, or authorized agent: _____________________________________________________________
Relationship to patient: _____________________________________________
Date: _______________________________
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Parent category: Legal