Patient authorizes the physicians, medical attendants, and the hospital to furnish full and complete medical information to the specified attorney at law, or to any representative or investigator from his/her firm. The form also provides that all prior authorization is cancelled.
Medical Information Authorization Without In Illinois
Category:
State:
Multi-State
Control #:
US-00426
Format:
Word;
Rich Text
Instant download
Description
Free preview
Form popularity
More info
Section A: Individual for whom medical records are being requested. First Name: Middle Name: Last Name: Previous Name (if applicable):.Freedom of Information Act requests must be made in writing and submitted to the Department's Freedom of Information Officer. However, employers are not allowed to require employees to provide medical information that is not relevant to their job duties. This authorization form allows patients to request and disclose their health information. Ensure that all sections are filled out correctly to avoid any delays. Here is a link to a WI healthcare power of attorney that you can print out, fill in and execute. You must select either "Yes" or "No. " Example: Jane has authorized Suzy to receive her health information that may have additional protections under state law.