HIPAA Authorization Form - Illinois
HIPAA AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (ILLINOIS)
(Comprehensive - HIPAA, Illinois Mental Health Confidentiality Act, AIDS Confidentiality Act, Substance Use Disorder Act, and GIPA)
1. PARTIES AND PURPOSE
Effective Date: [__/__/____]
This HIPAA Authorization ("Authorization") is executed by:
| Party | Identification |
|---|---|
| Individual / Patient | [Full Legal Name], DOB [__/__/____] |
| Covered Entity | [Provider / Plan / Clearinghouse Legal Name] |
| Authorized Recipient(s) | [Recipient Name(s), Title, Address] |
Purpose of Disclosure: [e.g., "continuity of care," "Social Security disability application," "litigation in Cook County Circuit Court Case No. ____," "at the request of the Individual"]
2. ILLINOIS PREEMPTION ANALYSIS
The following Illinois statutes impose requirements stricter than HIPAA and govern the corresponding categories of information disclosed pursuant to this Authorization:
| Information Category | Illinois Statute | Additional Requirement |
|---|---|---|
| Mental health / developmental disability records | 740 ILCS 110/5 | Patient-signed written consent specifying recipient, purpose, nature, right to inspect, consequences of refusal, and calendar expiration date |
| HIV/AIDS testing or status | 410 ILCS 305/9 | Specific written informed consent; HIV results may not be released except with written consent of all persons to whom information pertains |
| Substance use disorder treatment | 20 ILCS 301/30-5; 42 C.F.R. Part 2 | Separate Part 2-compliant consent; redisclosure prohibited without further consent |
| Genetic information | 410 ILCS 513/30 | Specific written authorization for release of genetic test results |
3. SPECIFIC INFORMATION AUTHORIZED FOR DISCLOSURE
3.1 General Medical Records. Covered Entity is authorized to use and disclose the following Protected Health Information ("PHI"):
[Describe categories, dates of service, and providers, e.g., "all medical records from 01/01/2020 through present, including physician notes, laboratory results, diagnostic imaging, discharge summaries, and billing records"]
3.2 Special Categories - Separate Initials Required. Disclosure of the following categories requires separate, specific initials to comply with Illinois law. If a category is NOT initialed, that category is NOT authorized for disclosure:
| Category | Authorize Disclosure | Statutory Basis |
|---|---|---|
| Mental health / developmental disability records | ☐ Initials: [____] | 740 ILCS 110/5 |
| Psychotherapy notes (separately maintained) | ☐ Initials: [____] | 45 C.F.R. § 164.508(a)(2) |
| HIV/AIDS testing, status, or treatment | ☐ Initials: [____] | 410 ILCS 305/9 |
| Alcohol or substance use disorder records | ☐ Initials: [____] | 20 ILCS 301/30-5; 42 C.F.R. Part 2 |
| Genetic information / genetic test results | ☐ Initials: [____] | 410 ILCS 513/30 |
| Sexually transmitted infection records | ☐ Initials: [____] | 410 ILCS 325 |
4. REQUIRED HIPAA ELEMENTS (45 C.F.R. § 164.508(c))
4.1 Specific and Meaningful Description of PHI. As set forth in Section 3 above.
4.2 Name of Person/Class Authorized to Make Disclosure. [Covered Entity Name and its workforce members].
4.3 Name of Person/Class to Whom Disclosure May Be Made. [Recipient Name(s) or Class].
4.4 Description of Each Purpose. As set forth in Section 1 above. If "at the request of the Individual," that statement is sufficient under HIPAA.
4.5 Expiration Date or Event. This Authorization expires on the earliest of:
☐ Calendar date: [__/__/____]
☐ Event: [Describe event, e.g., "conclusion of disability proceeding"]
☐ One (1) year from the Effective Date
4.6 Right to Revoke. Individual may revoke this Authorization in writing at any time by delivering signed notice to:
[Covered Entity Privacy Officer Name, Address]
Revocation is effective upon receipt, except to the extent that Covered Entity has already acted in reliance on the Authorization.
4.7 Inability to Condition Treatment. Covered Entity may NOT condition treatment, payment, enrollment, or eligibility for benefits on whether Individual signs this Authorization, except as permitted by 45 C.F.R. § 164.508(b)(4).
4.8 Re-Disclosure Warning. Information disclosed pursuant to this Authorization may be subject to re-disclosure by the Recipient and may no longer be protected by federal or Illinois privacy law. However: information protected by 740 ILCS 110, 410 ILCS 305, 20 ILCS 301/30-5, 410 ILCS 513, and 42 C.F.R. Part 2 may NOT be re-disclosed without further specific written consent of the Individual.
5. ADDITIONAL ILLINOIS-SPECIFIC ELEMENTS (740 ILCS 110/5)
For disclosure of mental health and developmental disability records, this Authorization specifies:
| Required Element | Specification |
|---|---|
| Person/agency to whom disclosure is made | [Recipient Name and Address] |
| Purpose for which disclosure is made | [As stated in Section 1] |
| Nature of information to be disclosed | [As stated in Section 3] |
| Right to inspect and copy the information | Individual has the right to inspect and copy the information being disclosed |
| Consequences of refusal to consent | [Describe, e.g., "no adverse consequence to treatment"] |
| Calendar date on which consent expires | [__/__/____] |
6. RIGHT TO RECEIVE A COPY
Individual is entitled to receive a signed copy of this Authorization. ☐ Copy provided to Individual.
7. SIGNATURES
Individual / Patient
Signature: ________________________________________________
Printed Name: ____________________________________________
Date: [__/__/____]
Personal Representative (if applicable)
Signature: ________________________________________________
Printed Name: ____________________________________________
Authority / Relationship: __________________________________
Date: [__/__/____]
Witness (recommended for Illinois mental health and HIV disclosures)
Signature: ________________________________________________
Printed Name: ____________________________________________
Date: [__/__/____]
8. SOURCES AND REFERENCES
- 45 C.F.R. § 164.508 (HIPAA authorization requirements)
- 45 C.F.R. § 160.203 (preemption of contrary state law)
- 740 ILCS 110/5 (Illinois Mental Health and Developmental Disabilities Confidentiality Act - consent requirements)
- 740 ILCS 110/4 (persons entitled to consent)
- 410 ILCS 305/9 (Illinois AIDS Confidentiality Act - written consent for HIV disclosure)
- 20 ILCS 301/30-5 (Illinois Substance Use Disorder Act - confidentiality)
- 42 C.F.R. Part 2 (federal substance use disorder confidentiality)
- 410 ILCS 513/30 (Illinois Genetic Information Privacy Act - disclosure)
- 42 U.S.C. § 1320d-5 (HIPAA civil penalties)
This Authorization is intended to satisfy HIPAA and applicable Illinois privacy statutes. Counsel should review for fitness to the specific transaction and patient population before use.
About This Template
These templates cover the everyday paperwork that happens between patients, providers, and health plans: consent forms, medical record authorizations, directives for end-of-life care, and requests to approve or deny treatment. Getting them right matters because they document medical decisions, release sensitive health information, and often have to meet both federal privacy rules and state-specific requirements. A form that is missing a required disclosure can be rejected by a provider or challenged later in court.
Important Notice
This template is provided for informational purposes. It is not legal advice. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Last updated: May 2026