Get Il Il462-0146 2012

The IL IL462-0146 form is essential for authorizing the disclosure and obtainment of personal health information. This guide will walk you through the process of filling out this form online, ensuring that you understand each component and requirement.

Follow the steps to successfully complete the IL IL462-0146 form.

1. Click the 'Get Form' button to access the IL IL462-0146 form in your preferred editor.
2. Identify whether you are authorizing the disclosure, obtainment, or both. Fill in the name of the hospital, agency, or individual involved.
3. Check the boxes for the specific documents you wish to disclose or obtain, such as discharge summaries or psychiatric evaluations. If you're unsure of a date, indicate the 'last service date.'
4. Provide the full name, date of birth, social security number, and any aliases of the individual whose information is being handled to ensure correct identification.
5. Mark the purpose for which the information is needed, such as personal use, continuity of care, or attorney needs.
6. Specify how the information may be disclosed or obtained, selecting from options like mail, in-person, phone, email, or fax. If there are any restrictions, include them.
7. Complete the name and address of the entity you are disclosing to or obtaining from, including city, state, and zip code.
8. Enter a specific expiration date for this authorization. This date indicates until when the authorization is valid.
9. Review sections explaining the recipient's rights to inspect and copy the information and understand the potential for re-disclosure.
10. Acknowledge and understand the potential consequences of refusing to sign this form for disclosure.
11. Review the sensitive information that may be released and check any exclusions to prevent unnecessary disclosures.
12. If you are an individual age 12 or older, sign and date in the designated space to authorize the disclosure.
13. If the individual is under 12, a guardian must sign and date on their behalf.
14. A witness must sign to verify the identity of the person giving consent.
15. Lastly, a staff person responsible for disclosing or obtaining information should sign and date the form.
16. Once all sections have been completed, save your changes, and you can download, print, or share the form as needed.

Complete the IL IL462-0146 form online today to ensure your authorization needs are met efficiently.