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
Phone # (required)
I hereby authorize:
Orthopedic Center of Illinois
1301 South Koke Mill Road
Springfield, IL 62711
To disclose to (Recipient):
(Self, Name of Individual, Health Care Agency, Insurance)
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.
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:
Patient Guardian Name and Relationship Authorizing: