Authorization To Disclose Health Information {HFS 3806D}

State of Illinois Department of Healthcare and Family Services Authorization To Disclose Health Information NOTICE: · Federal law says that Healthcare and Family Services (HFS) cannot share your health information without your permission except in certain situations. If you sign this form, you are giving HFS permission to share your health information that HFS has with the person you indicate below. · This authorization is voluntary. · Right to revoke : If you decide you do not want HFS to share your health information any longer, sign the revocation at the end of this form and give this form to HFS. If HFS has shared your health information for a research study, HFS may continue to use or share your health information for that purpose only. · Payment, enrollment or eligibility for benefits for your health care will not be affected if you do not sign this authorization, unless the disclosure is for eligibility or enrollment determinations, or for risk determinations. · HFS cannot promise that the person you permit HFS to share your health information with will not share your health information with someone else you may not want to have your health information. · You can keep a copy of this authorization, and can contact the HFS privacy officer to get a copy if you do not have one. My name (print) Social Security Number Date of Birth Recipient I.D. Number I give permission to: Healthcare and Family Services to share my health information with: so that this person or entity may assist me with my health care issues. HFS may share my health information for one year after the date on this authorization form or until I revoke the authorization. I want HFS to share this health information: (check all boxes that apply) All of my health information Information regarding prescription drug coverage My health information regarding Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV) My health information regarding treatment for alcohol and/or substance abuse My health information regarding behavioral health services or psychiatric care Other This form must be signed by EITHER the recipient OR by the personal representative. The recipient's parent may sign for the recipient if the recipient is a minor. Signature of Recipient Date If this form is signed by the personal representative, please include a copy of the document naming the personal representative, for example, a power of attorney, Personal Representative Designation form, or order appointing a guardian or executor. Signature of personal representative Relationship of personal representative Date HFS 3806D (R-7-14) American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 REVOCATION OF AUTHORIZATION I no longer want Healthcare and Family Services to share my health information with the person or entity indicated above. My name (print) Social Security Number Signature Date Send this Authorization Form or Revocation of Authorization to: Privacy Officer Office of the General Counsel Healthcare and Family Services 201 S. Grand Ave. East, 3rd Floor Springfield, IL 62763-1000 If you have any questions, contact the Privacy Office at the address to the left, or the phone number below. The call is free. Toll-free telephone: 1-800-226-0768 (Health Benefits Hotline) Toll-free for persons using a TTY: 1-877-204-1012 e-mail address: HFS.privacy.officer@illinois.gov Fax: 1-217-524-2397 HFS 3806D (R-7-14) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2