Form DOC0241 "Authorization for Release of Offender Medical Health Information" - Illinois

What Is Form DOC0241?

This is a legal form that was released by the Illinois Department of Corrections - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2005;
  • The latest edition provided by the Illinois Department of Corrections;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOC0241 by clicking the link below or browse more documents and templates provided by the Illinois Department of Corrections.

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Download Form DOC0241 "Authorization for Release of Offender Medical Health Information" - Illinois

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I
D
C
LLINOIS
EPARTMENT OF
ORRECTIONS
Authorization for Release of Offender Medical Health Information
This Authorization may not be used for mental health or substance abuse treatment information (use form DOC 0240)
The Department of Corrections will not condition treatment on this authorization. If authorizing disclosure to persons or
organizations that are not health plans, covered health care providers or health care clearinghouses subject to federal health
information privacy laws, they may further disclose the protected health information. However, genetic testing or HIV/AIDS
information disclosed pursuant to this authorization may not be further disclosed except pursuant to authorization.
I hereby authorize
to release the following information: (
State
Facility
specific medical health information to be disclosed including date(s) or date range)
.
At Request of Offender and/or:
Purpose of disclosure
from the records of
ID#
Print Offender's Name
to:
Self
Authorized Attorney
Health Care Facility
Other:
Name:
Print Name
Address:
Street Address
City
State
Zip Code
I hereby release and hold harmless, the State of Illinois, the Department of Corrections, and its employees from any liability which
may occur as a result of the disclosure or dissemination of the records or information contained therein resulting from the access
permitted to the authorized attorney, health care facility, other as specified, or self. Records disclosed may contain confidential
medical information including HIV disease information. I understand that I have the right to revoke this authorization at any time
prior to disclosure by giving written notice (witnessed by someone who knows my identity) to the prison Facility Privacy Officer.
Expiration: This authorization will expire (complete one):
45 days from date of signature
Upon the occurrence of the following event (must relate to the individual or purpose of the authorization):
Signature:
Signature of Offender or Person Authorized to Consent
Relationship
Date
Give Offender a copy if DOC made the request for release.
Distribution:
Offender's Medical File
DOC 0241 (Rev. 01/2005)
Printed on Recycled Paper
I
D
C
LLINOIS
EPARTMENT OF
ORRECTIONS
Authorization for Release of Offender Medical Health Information
This Authorization may not be used for mental health or substance abuse treatment information (use form DOC 0240)
The Department of Corrections will not condition treatment on this authorization. If authorizing disclosure to persons or
organizations that are not health plans, covered health care providers or health care clearinghouses subject to federal health
information privacy laws, they may further disclose the protected health information. However, genetic testing or HIV/AIDS
information disclosed pursuant to this authorization may not be further disclosed except pursuant to authorization.
I hereby authorize
to release the following information: (
State
Facility
specific medical health information to be disclosed including date(s) or date range)
.
At Request of Offender and/or:
Purpose of disclosure
from the records of
ID#
Print Offender's Name
to:
Self
Authorized Attorney
Health Care Facility
Other:
Name:
Print Name
Address:
Street Address
City
State
Zip Code
I hereby release and hold harmless, the State of Illinois, the Department of Corrections, and its employees from any liability which
may occur as a result of the disclosure or dissemination of the records or information contained therein resulting from the access
permitted to the authorized attorney, health care facility, other as specified, or self. Records disclosed may contain confidential
medical information including HIV disease information. I understand that I have the right to revoke this authorization at any time
prior to disclosure by giving written notice (witnessed by someone who knows my identity) to the prison Facility Privacy Officer.
Expiration: This authorization will expire (complete one):
45 days from date of signature
Upon the occurrence of the following event (must relate to the individual or purpose of the authorization):
Signature:
Signature of Offender or Person Authorized to Consent
Relationship
Date
Give Offender a copy if DOC made the request for release.
Distribution:
Offender's Medical File
DOC 0241 (Rev. 01/2005)
Printed on Recycled Paper