Get Authorization To Disclose/obtain Information - Illinois Department Of ... - Dhs State Il

Completing the Authorization To Disclose/Obtain Information form is essential for sharing important health information while ensuring compliance with privacy regulations. This guide will help you navigate the process of filling out this form online with clear and supportive instructions.

Follow the steps to efficiently complete the authorization form.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. Identify whether you are authorizing to disclose, obtain, or both. Select the appropriate option to indicate who you are allowing to perform these actions.
3. Specify the type of information you wish to disclose or obtain. Choose only what is minimally necessary for the purpose intended, and enter the relevant service date.
4. Fill in the individual's name, date of birth, social security number, and any aliases that could help accurately identify the person involved.
5. Indicate the purpose for which you require this information by checking the relevant options provided.
6. Circle all the manners in which the information may be disclosed or obtained, such as mail, phone, or email. If you want to restrict any method, specify those restrictions.
7. Complete the name and address of the agency, facility, or individual to whom you are disclosing the information or from whom you are obtaining it.
8. Enter the expiration date of the authorization. This should be a specific calendar date to ensure compliance.
9. Review the statement regarding the rights of the agency or individual receiving the information to inspect and copy it.
10. Understand that you can revoke this authorization at any time by providing a written notice to the relevant facility.
11. Be aware that refusal to sign the form will lead to the consequence that the requested information will not be disclosed or obtained.
12. Indicate whether sensitive information will be disclosed. If you wish to exclude any portions, check the appropriate boxes.
13. Sign the form appropriately based on the individual's age or status. Ensure the correct signatures are included as necessary.
14. Have a witness sign the form to attest to the identity of the person providing consent, if needed.
15. Finalize the form by entering the signature of the staff person disclosing or obtaining the information, along with the date and time.
16. Once all sections are completed, save your changes, download, print, or share the form as required.

Complete your documents online for a streamlined and efficient process.