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  • Authorized Relative Certification Form

Get Authorized Relative Certification Form

735 IL CD 5/8? 2001.5 Certification I ... A certified copy of the death certificate of ... Authorized Relatives signature .

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How to fill out the Authorized Relative Certification Form online

Filling out the Authorized Relative Certification Form online is a straightforward process designed to confirm your relationship to a deceased individual. This guide provides step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete the form correctly.

  1. Click ‘Get Form’ button to obtain the form and open it in the editor.
  2. In the first field, enter your name as the authorized relative of the deceased. Ensure that you fill in both your first and last name clearly.
  3. Next, provide the name of the deceased in the designated field. Again, be thorough in including both the first and last name.
  4. Attach a certified copy of the death certificate of the deceased. This is an essential requirement for submitting the form.
  5. In the certification section, affirm that to the best of your knowledge, no executor or administrator has been appointed for the deceased’s estate, and confirm that there are no objections to disclosure.
  6. Indicate your relationship to the deceased by checking the appropriate box, selecting either ‘Surviving spouse’ option or one of the listed relationships (adult son or daughter, parent, or adult sibling).
  7. Finally, date the form in the specified area, and print your name and sign as the authorized relative at the bottom.
  8. After completing the form, you can save changes, download, print, or share the form as needed.

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Answer: Yes, for a period of 50 years following the date of death of the individual. During this period, the Privacy Rule protects the identifiable health information of the deceased individual to the same extent the Rule protects the health information of a living individual.

Who is authorized to sign for the release of information to obtain a copy of the medical record? The patient. The parent or legal guardian. If the patient is deceased, the next of kin may sign for the patient with identification.

Who owns my medical record? Under Illinois law, your health care provider owns the actual medical record. For example, if your provider maintains paper medical records, they own and have the right to keep the original record. You only have the right to see and get a copy of it.

In Illinois, medical records must be retained for a minimum of 6 years. Desert River Solutions makes it easy for you to ensure your patients have access to their medical records for the legally required amount of time.

For access to a deceased patient's medical records Authorized Relative Certification: Submit a copy of the medical records request form and a copy of the death certificate with this form. Please complete the form in its entirety, and sign and date.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232