Get Dreyer Medical Records Release

Dreyer Medical Clinic Medical Records Department 1870 West Galena Boulevard Aurora Illinois 60506 Phone 630-859-7266 Fax 630-906-5902 Advocate AUTHORIZATION FOR RELEASE OF PATIENT HEALTH INFORMATION Please read both sides of this form carefully. Signature of Patient Date of Parent/Legal Guardian/Personal Representative Relationship Witness Re-disclosure Notice is hereby given to the patient or legal representative signing this Authorization that Dreyer Medical Clinic and Advocate Health Care cannot guarantee that the Recipient receiving the requested health information will not re-disclose any or all of it to others. The federal Health Insurance Portabili and Accountabiliy Act of 1996 HIPAA which became effective Apri114 2003 requires that all of the following elements must be completed for an authorization to be valid. Patient Name Street Address City State and Zip Code Phone Number Date of Birth I hereby authorize forwarded From that the protected health information regarding the above-named person be Person/Organization DREYER MEDICAL CLINIC Address 1870 W. GALENA BOULEVARD City. AURORA State IL Zip 60506 To- Recipient Address 120 W* MADISON STREET STE* 300 City. CHICAGO Purpose or Need for Information Disclosure FOR DISCOVERY BEFORE Zip* 60602 TRIAL will include check all that apply Face Sheet Operative X-ray/Radiology Pathology Report Discharge History Nurses Notes X Physical Laboratory EKGMG/EEG Summary Progress/Physician Emergency Consultation Notes Other Please see enclosed Subpoena or Letter Request for information to be disclosed* Records for the period to from continued on reverse I understand that I must check one or more of the following types of health information that I do noAt want released to the above-named Recipient. I understand that if I do not check any of the following three items the health information released to the named Recipient may include any of the following Diagnosis. evaluation Records of HTLV-III and/or treatment for alcohol and/or drug abuse or HIV testing AIDS test result diagnosis Psychiatric psychological records or evaluation and/or treatment for mental physical and/or emotional illness including narrative summary tests social work assessment medication psychiatric examination progress notes consultations treatment plans and/or evaluation I also understand that this Authorization is subject to revocation/withdrawal by me at any time in writing to the medical record contact person at this site of care except to the extent the action has already been taken to release this information* This Authorization shall remain valid unless revoked but will expire in one year after signing. I have a right to inspect a copy of the health information to be released and ifI do not sign this Authorization the organization named above wilI not release my health information* The above named person/organization will not refuse to treat me based on whether I agree to allow my health information to b6 Used and disclosed to others.