Illinois Department Of Healthcare And Family Services Medical Application Form (Page 3 of 3) in pdf

Illinois Department Of Healthcare And Family Services Medical Application Form Page 3

Illinois Department of Healthcare and Family Services

For Office Use Only

ATTN: Hemophilia Program

Identification

P.O. Box 19129

Springfield, IL 62794-9129

Patient Number

RELEASE OF INFORMATION

By signing this form, I __________________________________ authorize Illinois Hemophilia

(First Name

Last Name)

Program to release or retrieve any information, including protected health information or

PHI, to any insurance company, insurance company representative or other authorized third

party for the purpose of paying my claims. I authorize any holder of healthcare information or

documentation, including PHI, needed to determine benefits or benefits payable for related

services or any service rendered to me now or in the future to be released to Illinois

Hemophilia Program if requested. I authorize that direct payment be made by any insurance

company or other third party for any hemophilia charges that are reimbursable and owed to

Illinois Hemophilia Program.

Signature: __________________________________________

Date: _________________________

Day

Year

(Patient signature – If minor, parent or guardian signature)

IMPORTANT NOTICE: This State Agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under

Public Act 83-99. Disclosure of this information is mandatory.

I hereby certify that the answers given on this application and financial profile are correct and true to the best of my knowledge. I authorize the Illinois

Hemophilia Program or its representatives to verify all facts herein stated relative to my financial condition or income. I consent to the furnishing by

physicians or hospitals of any information requested by the Illinois Hemophilia Program regarding my diagnosis or treatment. A photocopy of this consent

will be as valid as the original. It is understood that all information will be treated as confidential.

REV 4-1-14