Form DOC0240 "Authorization for Release of Offender Mental Health or Substance Abuse Treatment Information" - Illinois

What Is Form DOC0240?

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 DOC0240 by clicking the link below or browse more documents and templates provided by the Illinois Department of Corrections.

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Download Form DOC0240 "Authorization for Release of Offender Mental Health or Substance Abuse Treatment Information" - Illinois

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I
D
C
LLINOIS
EPARTMENT OF
ORRECTIONS
Authorization for Release of Offender Mental Health or Substance Abuse Treatment Information
This Authorization may not be used for medical health information (use form DOC 0241)
The Department of Corrections will not condition treatment on this authorization. Mental health information disclosed pursuant to this authorization
may not be further disclosed except pursuant to authorization from the offender or offender's representative. If this authorization is for psychotherapy
notes, it must not be used as an authorization for any other type of protected health information.
I hereby authorize
to release
Facility
Section A: Mental Health Information
:
(State specific Mental Health information to be disclosed including date(s) or date range)
.
Section B: Substance Abuse Treatment Information
:
(as indicated below)
If Substance Abuse Treatment records are being authorized, initial all relevant areas below (
:
including date(s) or date range)
Diagnosis
Toxicological Reports/Drug Screens
Evaluation/Assessment
Medication Management Information
Treatment Plan
Attendance in Treatment
Summary of Treatment Services
Treatment Progress Report
Continuing Care Plan
Educational Information
Other (specify):
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. 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 o
ccurrence 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
Witness:
Print Name
Title
Signature
Date
Give Offender a copy if DOC made the request for release.
Distribution:
Offender's Medical File
DOC 0240 (Rev. 01/2005)
Printed on Recycled Paper
I
D
C
LLINOIS
EPARTMENT OF
ORRECTIONS
Authorization for Release of Offender Mental Health or Substance Abuse Treatment Information
This Authorization may not be used for medical health information (use form DOC 0241)
The Department of Corrections will not condition treatment on this authorization. Mental health information disclosed pursuant to this authorization
may not be further disclosed except pursuant to authorization from the offender or offender's representative. If this authorization is for psychotherapy
notes, it must not be used as an authorization for any other type of protected health information.
I hereby authorize
to release
Facility
Section A: Mental Health Information
:
(State specific Mental Health information to be disclosed including date(s) or date range)
.
Section B: Substance Abuse Treatment Information
:
(as indicated below)
If Substance Abuse Treatment records are being authorized, initial all relevant areas below (
:
including date(s) or date range)
Diagnosis
Toxicological Reports/Drug Screens
Evaluation/Assessment
Medication Management Information
Treatment Plan
Attendance in Treatment
Summary of Treatment Services
Treatment Progress Report
Continuing Care Plan
Educational Information
Other (specify):
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. 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 o
ccurrence 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
Witness:
Print Name
Title
Signature
Date
Give Offender a copy if DOC made the request for release.
Distribution:
Offender's Medical File
DOC 0240 (Rev. 01/2005)
Printed on Recycled Paper