State of Illinois
Department of Human Services
Authorization to Release Medical Records
Section A: Individual for whom medical records are being requested.
Previous Name (if applicable):
Date of Birth:
Daytime telephone number(s):
Section B: Person or organization from whom medical records are requested.
Section C: Send requested medical information to:
Illinois Department of Human Services
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
Psychiatric Outpatient Notes (pre/post hospitalization)
Section E: Purpose