Illinois Authorization To Release Medical RecordsIllinois Authorization To Release Medical Records
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State of Illinois
Department of Human Services

4(12 Months)

Authorization to Release Medical Records
Section A: Individual for whom medical records are being requested.
First Name:

Middle Name:

Last Name:

Previous Name (if applicable):
Street Address:

Date of Birth:

City/State/Zip:

Daytime telephone number(s):

Section B: Person or organization from whom medical records are requested.
Hospital/agency/clinic/physician:

Attention:

Address:
Phone:

Fax:

Section C: Send requested medical information to:
Illinois Department of Human Services
FCRC:

Attention:

Address:
Phone:

Fax:

Section D: Information to be disclosed from DATE (or RANGE OF DATES)
Check information needed.
History and Physical
Physician's Discharge Summary
Emergency Department Record
Diagnostic Test Reports

Pathology Reports
Progress Notes
Rehab Records
Social History

Date:

Consultation Reports
Behavior Plans
Psychiatric Evaluation
Psychiatric Outpatient Notes (pre/post hospitalization)

Section E: Purpose