Illinois HIPAA Authorization To Use And Disclose Health InformationIllinois HIPAA Authorization To Use And Disclose Health Information
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HIPAA AUTHORIZATION TO USE AND
DISCLOSE HEALTH INFORMATION
To release the personal health information of:
Patient’s Name:_____________________________________________ Phone#: _________________ Date of Birth:____________
Address: _____________________________________________ City: ____________________ State: ______ Zip: ___________
To release to: Recipient: ___________________________________________________________ Phone #: __________________
Address: _____________________________________________ City: ____________________ State: ______ Zip: ___________
To release from: Releasing Entity: ___________________________________________________ Phone #: __________________
The purpose of this disclosure is: ❑ At the request of the individual ❑ Other: ______________________________________
The dates of patient care covered by this Authorization are: _______________________________________________________
Release the Following Information:
❑ Discharge Summary
❑ Pathology Report(s)
❑ Emergency