AUTHORIZATION FOR RELEASE OF
CONFIDENTIAL HEALTH INFORMATION
Date of Birth
I hereby authorize the protected health information regarding the above-named person to be exchanged to:
I authorize the release of information pertaining to the following time periods:
The following types of information to be disclosed are as follows:
History and physical examination
Abstract (documents summarizing history)
Diagnostic reports (labs, x-rays, etc.)
The following highly CONFIDENTIAL items must be checked off to be included in the disclosure:
HIV/AIDS related health information/records (410 ILCS 305/9)
Behavioral or mental health information/records (740 ILCS 110/1 et seq)
Drug/alcohol diagnosis, treatment, referral information (20 ILCS 301/30.5; 42 CFR Pt. 2)
Individual Genetic (not fetal) testing information/records (410 ILCS 513/30)
The purpose(s) of this authorization is (are):
This authorization expires (date):
If not specified, this release will expire 1 year after the date of signature.
I 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.
I 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.
I 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.
I understand that this authorization is valid until it expires, unless revoked before that.
I 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 of my health information. Written revocation must be sent to the physician’s office.
I have read and understood the terms of this Authorization and I have had the opportunity to ask questions about theuse and disclosure of my health information. By my signature, I knowingly and voluntarily authorize Gynecological and Obstetric Associates, S.C. to use or disclose my health information in the manner described above.
Patient, legal guardian, or authorized agent
Relationship to patient
Signature of Patient, Legal Guardian or Authorized Agent
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.