Authorization to Use or Disclose Protected Health Information

This authorization may be used to permit a covered entity (as such term is defined by HIPAA and applicable Illinois law) to use or disclose an individual’s protected health information. Individuals completing this form should read the form in its entirety before signing and complete all the sections that apply to their decisions relating to the use or disclosure of their protected health information.

Information regarding patient for whom authorization is made:
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Please Enter a Valid Phone Number

(xxx) xxx-xxxx or xxxxxxxxxx are valid formats.

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Please Enter a Valid E-mail Address.

Example: JSmith@theinternet.com

Please Select a State

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Please Enter a Valid ZIP Code

Information regarding health care provider or health care entity authorized to disclose this information:
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Please Enter a Valid Phone Number

(xxx) xxx-xxxx or xxxxxxxxxx are valid formats.

Please Select a State

Please Enter a Valid Phone Number

(xxx) xxx-xxxx or xxxxxxxxxx are valid formats.

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Please Enter a Valid E-mail Address.

Example: JSmith@theinternet.com

Please Enter a Valid ZIP Code

Information regarding person or entity who can receive and use this information:
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Please Enter a Valid Phone Number

(xxx) xxx-xxxx or xxxxxxxxxx are valid formats.

Invalid Input

Please Enter a Valid Phone Number

(xxx) xxx-xxxx or xxxxxxxxxx are valid formats.

Please Select a State

Please Enter a Valid E-mail Address.

Example: JSmith@theinternet.com

Please Enter a Valid ZIP Code

Specific information to be disclosed:
Medical Records
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The individual signing this form agrees and acknowledges as follows:


(i) Voluntary Authorization: This authorization is voluntary. Treatment, payment, enrollment or eligibility for benefits (as applicable) will not be conditioned upon my signing of this authorization form.


(ii) Effective Time Period: This authorization shall be in effect until the earlier of two (2) years after the death of the patient for whom this authorization is made or the following specified date:

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(iii) Right to Revoke: I understand that I have the right to revoke this authorization at any time by writing to the health care provider or health care entity listed above. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.


(iv) Special Information: This authorization may include disclosure of information relating to DRUG, ALCOHOL and SUBSTANCE ABUSE, MENTAL HEALTH INFORMATION, except psychotherapy notes, CONFIDENTIAL HIV/AIDS-RELATED INFORMATION, and GENETIC INFORMATION only if I place my initials on the appropriate lines above. In the event the health information described above includes any of these types of information, and I initial the corresponding lines in the box above, I specifically authorize release of such information to the person or entity indicated herein.

Sign and Confirm
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