Authorization to Release Records

Patient Name *

Date of Birth *

Phone

Address *

City/State *

Zip Code *

I authorize Illinois Bone and Joint Institute to use/disclose a copy of the specified protected health information as indicated below to (Recipient):

Recipient Name

Phone

Fax

Address/Email

City

State

Zip

I understand that if this information is emailed per my request, there may be some level of risk that this information could be read by an unauthorized third party.

Send the entire medical record (all information) to the above named recipient.

Send only the following information to the above named recipient:

Records for the period (dates) From

Purpose or need for information:

Continuation of care

Personal Use

Other/Describe:

I understand that my medical record may include information relating to treatment for mental health, STDs, AIDS, HIV, or alcohol and/or substance abuse, and genetic testing results. If you do not wish such information to be released, check which of the information you wish to be excluded below*.

HIV/AIDS/STD related information/records

Genetic testing information/records

Mental health information/records

Drug/alcohol diagnosis, treatment or referral

I understand that if the person or entity that receives the above information is not a healthcare provider or health entity covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations.

I understand that this authorization is voluntary and my ability to obtain treatment or payment or my eligibility for benefits will not be conditioned on signing this authorization. I may inspect or receive a copy of any information used/disclosed under this authorization.

I understand that I may revoke this authorization at any time, provided that I do so in writing, except in the instance that action has already been taken in reliance upon this authorization. I understand that this authorization will expire on the following specific date, event, or condition related to the purpose of this disclosure

Unless otherwise specified, this form expires one year from date of signature.