Authorization Release - Illinois CancerCare

Authorization For Release of Confidential Health Information

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"*" indicates required fields

Required fields marked with a *

I hereby authorize Illinois CancerCare, P.C. (“ILCC”) to release to:*

Patient Name*

First Last

Patient Date of Birth*

The following information may be released:*

By checking any of the lines below, I am specifically authorizing ILCC to use and/or disclose the category of confidential Information indicated next to the line, if applicable to this authorization.

Genetic Testing (ex: BRCA, PTEN, MSH2, etc)

Drug Abuse Treatment Records

HIV/Acquired Immune Deficiency Syndrome (AIDS) Records

Alcoholism Treatment Records

Mental Health Treatment Records

The above information for the following period of time shall be released:*

Please insert a start and end date

How would you like to receive the records?*

Postal Mail

Fax

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Name of Facility*

Fax Number*

Authorization for Release of Protected Health Information and Patient Rights*

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 ILCC 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 the 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 ILCC of my desire to do so. I also understand that I will not be able to revoke this authorization in cases where ILCC has already relied on it to use or disclose my health information. Written revocation must be sent to ILCC at the following address: 8940 N Wood Sage Rd, Peoria, IL 61615, Attn: Christy Kurland.

Absent such written revocation, this Authorization for Release of Confidential Heath Information will terminate twelve months from the date below.

NOTICE TO RECIPIENT OF PROTECTED HEALTH INFORMATION: No records or information from such records which are within the provisions of (1) the Illinois Mental Health and Developmental Disabilities Confidentiality Act, (2) the Federal Act of July 1, 1975, Confidentiality of Alcohol and Drug Abuse Patient Records, (3) the Illinois AIDS Confidentiality Act, (4) the Illinois Genetic Confidentiality Act, or (5) other similar laws, may be further disclosed unless the person who executed the Authorization specifically consents, in writing, to such re-disclosure. A general authorization for release of medical or other information is not sufficient for this purpose.

Signed

Today's Date*

If you are not the patient, please state the basis for your authority to act on behalf of the patient:

Representative Name

First Last

Representative Phone

Representative Email

Representative Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

NOTICE TO RECIPIENT OF PROTECTED HEALTH INFORMATION: No records or information from such records which are within the provisions of (1) the Illinois Mental Health and Developmental Disabilities Confidentiality Act, (2) the Federal Act of July 1, 1975, Confidentiality of Alcohol and Drug Abuse Patient Records, (3) the Illinois AIDS Confidentiality Act, (4) the Illinois Genetic Confidentiality Act, or (5) other similar laws, may be further disclosed unless the person who executed the Authorization specifically consents, in writing, to such re-disclosure. A general authorization for release of medical or other information is not sufficient for this purpose.

Phone

This field is for validation purposes and should be left unchanged.