Release Patient Form -

Name (First, Middle, Last)

Phone Number

Date of Birth

Address

Release Information FROM (check all that apply)

Choose one optionGreater Chicago Specialty Physicians’ facilitiesOther facilities

Other facilities details

specify physician/facility

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone

Release Information TO

Choose one optionGreater Chicago Specialty Physicians’ facilitieOther

Other facilities details

Name of Recipient

Address

Phone

Delivery Preference

Release the following health information within the following dates

From

Declaration

Accept the T&C

Authorization Notice

I understand:

This authorization will remain in effect for one year from the date of authorization written below. You or your Personal Representative may revoke this authorization at any time by providing written notice as specified in our Notice of Privacy Practices.
There will be a charge for processing this request in accordance with Illinois law.
Once this information is shared with the recipient you specified above, how that recipient further discloses it may no longer be protected under federal and state privacy regulations.
I understand the matters discussed on this form and release Greater Chicago Specialty Physicians, its employees, officers and directors, and business associates from any legal responsibility or liability for the disclosure of the above information.