Medical Records Authorization (HIPAA) - Illinois

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (ILLINOIS)

This Authorization complies with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. § 164.508, and applicable Illinois law.

1. PATIENT IDENTIFICATION

2. PROVIDER(S) AUTHORIZED TO RELEASE RECORDS

I authorize the following health care provider(s), facility(ies), and their business associates to release my protected health information ("PHI") as described below:

3. RECIPIENT(S) — WHO MAY RECEIVE THE RECORDS

PHI shall be released to:

4. RECORDS / INFORMATION TO BE RELEASED

☐ Complete medical record
☐ Only records for the following date range: [__/__/____] to [__/__/____]
☐ Only records relating to the following incident/condition: [________________________________]

Record types (check all that apply):

☐ History and physical / office notes
☐ Physician and nursing notes; bedside notes; charts
☐ Hospital / emergency-department records
☐ Diagnostic imaging (X-ray, MRI, CT) films, pictures, and plates
☐ Laboratory and pathology results
☐ Operative and procedure reports
☐ Physical therapy / rehabilitation records
☐ Prescription and medication records
☐ Itemized billing statements and insurance records
☐ Other: [________________________________]

5. PURPOSE OF DISCLOSURE

This disclosure is made at the request of the patient for the following purpose: evaluation, investigation, prosecution, and settlement of the patient's personal-injury claim, including legal representation.

☐ Other purpose: [________________________________]

6. HIPAA CORE-ELEMENT RECITALS

6.1 Expiration. This Authorization expires on the earlier of: (a) [__/__/____]; (b) the following event: [final resolution of the personal-injury claim]; or (c) if no date or event is stated, two (2) years from the date of signature.

6.2 Right to Revoke. I may revoke this Authorization at any time by delivering a written, signed revocation to the provider's privacy officer at the address in Section 2. Revocation is not effective as to action already taken in reliance on this Authorization before the revocation is received.

6.3 No Conditioning. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this Authorization, except as permitted by 45 C.F.R. § 164.508(b)(4).

6.4 Redisclosure Notice. Information disclosed under this Authorization may be subject to redisclosure by the recipient and may then no longer be protected by HIPAA or Illinois law. Mental-health, HIV/AIDS, genetic, and substance-use-disorder information remains subject to redisclosure restrictions under Illinois and federal law.

6.5 Copy. I am entitled to a copy of this signed Authorization.

7. SPECIAL-CATEGORY RECORDS — SEPARATE SPECIFIC AUTHORIZATION REQUIRED

I specifically authorize release of the following protected categories (initial each that applies; leaving a line blank means that category is NOT authorized):

Part 2 warning: Initialing this general authorization does not itself create a consent that satisfies 42 C.F.R. § 2.31. Use a standalone consent containing every applicable current § 2.31 element. If the records will be used or disclosed in a civil, criminal, administrative, or legislative investigation or proceeding, § 2.31(d) prohibits combining that consent with a consent for any other purpose. Each disclosure made under a valid consent must also carry one of the notices permitted by § 2.32(a) and a copy of the consent or a clear explanation of its scope under § 2.32(b).

8. ILLINOIS MENTAL HEALTH / DEVELOPMENTAL DISABILITIES CONSENT (740 ILCS 110/5)

Complete this section ONLY if mental-health or developmental-disability records are authorized in Section 7.

I understand that I may revoke this mental-health consent in writing at any time and that the information disclosed may not be redisclosed without my express written consent.

Patient (or authorized person) signature: ________________________________ Date: [__/__/____]

9. COPY FEES AND RESPONSE TIME (ILLINOIS)

Under 735 ILCS 5/8-2001, an Illinois health care facility or practitioner must permit examination and copying of patient care records upon presentation of a valid authorization. Charges are capped by statute (figures are adjusted annually by the Illinois Comptroller): a per-page rate (tiered: highest for the first 25 pages, lower for pages 26–50, lowest beyond 50), a per-page rate for microfiche/microfilm, and 50% of the per-page paper rate for records produced from electronic/digital format, plus a handling charge and actual postage. One complete copy must be provided without charge when records are requested to support a claim for federal veterans' disability benefits, Social Security/SSI benefits, or Aid to the Aged, Blind, or Disabled benefits. Records maintained electronically must be provided electronically on request.

10. SIGNATURE

Personal representative (if patient is a minor, incapacitated, or deceased):

11. NOTARY (OPTIONAL)

State of Illinois, County of [________________]

Subscribed and sworn before me this [____] day of [____________], 20[____].

Notary Public: ________________________________ My commission expires: [__/__/____]

SOURCES AND REFERENCES

• 45 C.F.R. § 164.508 — HIPAA authorization core elements: https://www.ecfr.gov/current/title-45/section-164.508
• 42 C.F.R. Part 2 — Confidentiality of SUD patient records: https://www.ecfr.gov/current/title-42/part-2
• 735 ILCS 5/8-2001 — Examination of health care records / copy fees: https://www.ilga.gov/legislation/ilcs/fulltext?DocName=073500050K8-2001
• 740 ILCS 110/ — Mental Health and Developmental Disabilities Confidentiality Act: https://law.justia.com/codes/illinois/chapter-740/act-740-ilcs-110/
• 410 ILCS 305/ — AIDS Confidentiality Act: https://law.justia.com/codes/illinois/chapter-410/act-410-ilcs-305/
• 410 ILCS 513/ — Genetic Information Privacy Act: https://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1567