Free Illinois Authorization For Release Of Confidential Health Information PDF Download

Health Service Northwestern University

633 Emerson Street

Evanston, Illinois 60208-4000

Phone 847-491-8100

Fax 847-491-8699

AUTHORIZATION FOR RELEAS E OF CONFIDENTI AL INFORMATION

Requests for Mental/Behavioral Health records MUST be made through Counseling and Psychological Services, please call 847-491-2151.

Patient Name (Please Print) Date of Birth Name as a student (if different than above) Student ID Year Entered NU E-mail Phone _

PLEASE RELEASE THE FOLLOWING HEALTH INFORMATION:

CHECK OFF EACH ITEM TO BE RELEASED. Requests for HIV/AIDS and/or Alcohol/Drug records require that you initial below.

Be as specific as possible:

X-Ray Report Initial for release of Alcohol/Drug record

X-Ray Film – Charge applies Initial for release of HIV/AIDS record

TB Test Result

Immunizations – Specify from Evanston or Chicago campus record:

Physical Examination

Lab Report(s) – List type of report(s) or approximate date(s):

Visit Note(s) – List approximate dates:

Other (specify):

ENTIRE HEALTH RECORD - $25.00 Charge applies unless sent to another healthcare provider.

Reason for requesting information (e.g. further care, insurance claim, etc.):

I AUTHORIZE THE HEALTH SERVICE TO RELEASE MY HEALTH INFORMATION TO (Recipient):

NOTE: If authorizing release to multiple recipients, a separate form must be submitted for each recipient.

Name Phone (Required for all fax requests) Address Fax City State Zip Code

Initial below to identify how you want your health information released to the recipient:

MAIL FAX - 10 page maximum, student will be contacted if request exceeds limit _ Phone/Verbal

PICK-UP - When my records are ready to be picked up, notify me by: E-mail Phone

MAIL THIS FORM TO: Northwestern University Health Service, Health Information Management Services, 633 Emerson Street, Evanston, Illinois 60208-4000 OR FAX TO: 847-491-8699

*A $25.00 CHARGE APPLIES FOR A COPY OF AN ENTIRE HEALTH RECORD UNLESS SENT TO ANOTHER HEALTHCARE PROVIDER. PAYMENT MUST BE MADE PRIOR TO RECORDS BEING RELEASED. CALL 847-491-2139 FOR DETAILS ON CHARGES FOR RELEASE OF X-RAY FILMS. CHECKS SHOULD BE MADE PAYABLE TO NORTHWESTERN UNIVERSITY.

REQUESTS ARE PROCESSED WITHIN 3-5 BUSINESS DAYS OF RECEIPT.

Call 847-491-2142 if you have questions about your release.

NOTIC E T O P ATIENT

I fully understand that my medical record and health information for the above date may contain alcohol/drug abuse, and/or Acquired Immune Deficiency Syndrome/HIV test results and/or mental health information and/or other information. I understand that any of the above selected records may contain medical information from outside sources and authorize NUHS to release these records and health information if necessary for continuity of care or if I have requested my complete record. I understand that I have the right to inspect and/or obtain a copy, (for the appropriate fee) of my medical record prior to disclosure. I understand that this consent applies both to written and verbal release of information and is valid for 90 days from the date of signature, or until calendar date

. I understand that I may revoke this consent at any time by giving written notice to Health Information Management Services of Northwestern University Health Service. I absolve Northwestern University and its agents or employees from any legal liability which may arise from the disclosure of this information.

Signature of patient or authorized legal guardian Date

Relationship to patient, if signed by authorized representative Date

Signature of staff member who received form at NUHS Date

For Office Use Only ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Number of pages

Date sent/initials

Date ready for pick-up

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Release of information/revised 05/08