Authorization for Medical Release

 Please Note:  All Attorney/Legal requests must originate from the law office requesting patient information.

 


Patient Name (Include any Alias)
Birth Date (required)
Last 4 digits of SSN
Email (required)
Address
City
State
Zip
Phone # (required)

I hereby authorize:

Orthopedic Center of Illinois 1301 South Koke Mill Road Springfield, IL 62711 Phone: 217-547-9100 Fax: 217-547-9236

To disclose to (Recipient):

(Self, Name of Individual, Health Care Agency, Insurance)
Address
City
State
Zip
Phone #
The following information:






OCI Physician(s)/Physical Therapist & Date(s) of Service:
This disclosure is made for the purpose of: (required)

Note: The release will include Genetic, HIV/AIDS. Drug/Alcohol, Mental Health or Developmental Disability information unless the specific box is checked below to exclude this information:




- I understand the Orthopedic Center of Illinois requires 7 to 10 days to process this request and may need up to 30 days as allowed by Federal Law.

- I have the right to inspect and obtain a copy of the records that are to be disclosed. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. However, this information will continue to be protected by Illinois Law, and may be subject to re-disclosure by the recipient ONLY if I specifically provide permission for the re-disclosure.

- I understand that this authorization is voluntary. I understand that the person(s) or organization(s) authorized to make requested use and/or disclosure may not condition the provision of treatment on the provision of an authorization.

- I understand that I may revoke this authorization at any time. I understand if I revoke this authorization, I must do so in writing and present my written revocation to the office authorized above to make the release. I understand the revocation will not apply to information that has already been released in response to this authorization.

Authorization Expiration:

This authorization will expire on the above date or event. If I do not specify an expiration date or event, this authorization will expire in 12 months from the signature date.

Select Method of Delivery:

Entering a name below serves as an electronic signature, by doing so you agree to all terms and authorize release of information.

Patient Name Authorizing:
Date:
Patient Guardian Name and Relationship Authorizing:
Date:
1301 South Koke Mill Road
Springfield, Illinois 62711