Authorization For Release Of Patient Health Information (Page 2 of 2) in pdf

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Information about sexuality transmitted disease (the patient 12 or over must authorize this release)

Pregnancy (the patient 12 or over must authorize this release)

Birth Control (the patient 12 or over must authorize this release)

Drug/Alcohol Diagnosis, Treatment and/or Referral Information (the patient 12 or over must authorize this release)

Genetic Testing Information and/or Records

Information about Sexual Assault/Abuse

Information about Child Abuse and Neglect

SECTION 7 - Authorization Expiration Date

This authorization is approved for:

This occurrence only

60 days from the date of signature Date:

____________________

1 year from the date of signature (mental health records only) Date:

________________

*Only effective for this occurrence if none is chosen

SECTION 8 - Please read the following statements carefully:

This authorization is voluntary. Presence Health will not condition your treatment on giving this authorization. However, Presence Health may condition the provision of research-

related treatment on the provision of an authorization.

I understand that I may change my mind and revoke this authorization at any time by giving written notice of my revocation to Presence Health. I understand that revocation of

this authorization will not affect action you took in reliance in this authorization before you received my written notice of revocation.

I authorize the use and/or disclosure of my Protected Health Information (PHI) as described above. I understand that this authorization is voluntary and made to confirm my

decision so Presence Health may use and/or disclose my PHI for a specific purpose. I understand that, if the persons or organizations I authorized above to receive and/or use the

PHI described above are subject to federal health information privacy laws, they may further disclose the PHI and it may no longer be protected by federal health information

privacy laws. However, any mental health, substance abuse, genetic testing or HIV/AIDS information disclosed by Presence Health pursuant to the authorization may not be further

disclosed except pursuant to my authorization.

I have had full opportunity to read and consider the contents of this authorization and I confirm that the contents are consistent with my direction to you. I understand that, by

signing this form, I am confirming my authorization that you may use and/or disclose to the persons and/or organizations named in this form the PHI described in this form.

I understand there may be a reasonable charge to obtain a copy of these records. I understand that I am entitled to a copy of this authorization after signing below.

Notice to receiving Agency/Person: Under the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, you may not redisclose any of this

information unless the person who consented to this disclosure specifically consents to such redisclosure. Under the Federal Act of July 1, 1975, Confidentiality of Alcohol and Drug

Abuse Patient Records, no such records, or information from such records may be further disclosed without specific authorization for such redisclosure.

SECTION 9 - Signature

Patient Signature:

Date:

Personal Representative Name: (Print)

Personal Representative Phone #:

Personal Representative Relationship to Patient and Authority:

Personal Representative Signature:

Date:

Witness Name (required for the release of mental health information):

Date:

Witness Signature:

Date: