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Get 3806f 2009-2024

East 3rd Floor Springfield IL 62763-1000 HFS 3806F R-7-14 If you have any questions contact the Privacy Office at the address to the left or the phone number below. State of Illinois Illinois Department of Healthcare and Family Services Personal Representative Designation Federal law says that the Illinois Department of Healthcare and Family Services Agency cannot share your health information without your permission except in certain situations. If you sign this form you are giving the Agency permission to treat the person s you name as your Personal Representative and to share your health information with that person* You can name more than one person as your Personal Representatives. This Personal Representative Designation will last until you tell the Agency you do not want it to treat the person s you name below as your Personal Representative any longer. Right to Revoke If you decide you do not want the Agency to treat the person s you name below as your Personal Representative any longer sign the Revocation at the end of this form and give this form to the Agency. Any revocation can only apply on and after the date the Agency receives the Revocation* The Agency cannot cancel disclosures it made to the Personal Representative before it received the Revocation* You can keep a copy of this Personal Representative Designation and can contact the Healthcare and Family Services Privacy Officer to get a copy if you do not have one. Date of Birth My Name Recipient I. D. Number RIN I name the following person s to act as my Personal Representative This person has all the rights that I have regarding my health information that the Agency has. This person is acting as my Personal Representative only for these functions Term of Authorization The Agency may share my health information from the date of this Personal Representative Designation until I revoke the Personal Representative Designation by signing the Revocation below and giving the Revocation to the Agency. Signature Date REVOCATION I no longer want the person named above to act as my Personal Representative. Send this Personal Representative Designation Office of the General Counsel Healthcare and Family Services 201 S* Grand Ave. The call is free. Toll-free telephone 1-800-226-0768 Health Benefits Hotline Toll-free for persons using a TTY 1-877-204-1012 Fax 1-217-524-2397 e-mail address HFS*privacy. State of Illinois Illinois Department of Healthcare and Family Services Personal Representative Designation Federal law says that the Illinois Department of Healthcare and Family Services Agency cannot share your health information without your permission except in certain situations. If you sign this form you are giving the Agency permission to treat the person s you name as your Personal Representative and to share your health information with that person* You can name more than one person as your Personal Representatives. If you sign this form you are giving the Agency permission to treat the person s you name as your Personal Representative and to share your health information with that person* You can name more than one person as your Personal Representatives. This Personal Representative Designation will last until you tell the Agency you do not want it to treat the person s you name below as your Personal Representative any longer. .

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