Instructions for Completing the Authorization Form

Provide your full name, date of birth, and a phone number where you can be reached during business hours, and mark the appropriate line indicating whether we should mail the records or you plan to pick them up.

Complete the numbered blanks as follows:

1. Enter the name of the organization/facility/person with the information to be disclosed. If this is not Christie Clinic, provide the full address.

2. Enter the name of the organization/facility/person you want the records sent to. Again, provide the full address if this is not Christie Clinic.

3. Indicate specifically which records you want to have copied. Examples: all pediatric records, ortho records regarding shoulder injury, obstetrical records from 2000 to present.

4. State the purpose for your disclosure. Examples: claim determination, workers comp. case, attorney, personal request.

5. Review paragraph 5, and initial it if you agree with the statement. (If this is not initialed and there is any reference to confidential diagnoses, we will not be able to comply with your request.)

6. Review, and make any changes you feel necessary.

7. Review.

8. Review the remainder of the form; sign it, and date it. If you are not the patient, please indicate your relationship to the patient.

If you have questions, please call 217.366.9656 for assistance.

Downloads

• Authorization to Disclose Health Information (29kb)Authorization to Disclose Health Information Form
• Authorization to Disclose Health Information: Verbal Release (36kb)Authorization to Disclose Health Information: Verbal Release Form
• Life Imaging™ (Radiology) Record Release (68kb)Life Imaging™ (Radiology) Record Release Form

Tags: medical records, forms, records