Consent and Release for Disclosure of Medical Information - Illinois

This "Consent and Release for Disclosure of Medical Information" is a Illinois-specific form released by the Illinois Department of Human Rights on February 1, 2014.

Download the form by clicking the link below, fill it out by hand, and mail it as per the guidelines provided by the department or the applicable legal instructions.

ADVERTISEMENT
CONSENT AND RELEASE FOR DISCLOSURE OF MEDICAL INFORMATION
I have filed a charge of discrimination with the Illinois Department of Human Rights (IDHR) related to my
following medical condition(s).
IDHR Charge Number:
Medical Condition(s):
Relevant Date(s):
I hereby permit the Health Care/Social Service Professional identified below, or other authorized medical
professional at the same facility, to complete the Verification of Disability Form and return the completed form to
the IDHR, and to answer any questions IDHR my have regarding the information contained in this form. Please
send all correspondence to the attention of the investigator assigned to my case, or if no investigator is listed below,
to the Fair Housing Unit.
Health Care or Social Service Professional:
Address:
Telephone No.:
(Note to Complainant: if an investigator has not yet been assigned to your case, or if you do not know the name of
your investigator, please leave the following blank.)
Investigator:
I understand that:
IDHR is requesting this information for the purpose of investigating my charge of discrimination
The completed Verification of Disability Form, once returned to IDHR, will become part of IDHR's
investigation file and may be subject to disclosure through subpoena, the Illinois Freedom of Information
Act, or any other lawful means to the parties, the general public, or other governmental agencies, including
the U.S. Department of Housing and Urban Development, local human rights agencies or commissions, or
the Office of Executive Inspector General for the Agencies of the Illinois Governor.
In lieu of signing this Consent and Release for Disclosure of Medical Information, I may submit
information from other sources regarding my identified condition, such as my testimony regarding my
condition, determinations of disability from the U.S. Social Security Administration, Family and Medical
Leave Act forms, or other similar documentation to show that my condition constitutes a disability within
the meaning of the Illinois Human Rights Act.
I have the right to decline to sign this consent and release, and if I do so, IDHR will make a determination
on my charge with other information and evidence obtained during the investigation, including any other
information I submit.
This consent form will expire one (1) year from the date of my signature below and may not be used after
that date.
Signature of Patient (Complainant) or other person
Date
legally entitled to give consent
Patient's Name (Complainant's Name - Printed)
Patient's Date of Birth
Address
City, State, ZIP Code
Date
Witness Signature (Person who can attest to the
identity of the Patient or other person entitled to give
consent)
Witnessed by (Name - Printed)
Verification of Disability (Housing)
2/14
CONSENT AND RELEASE FOR DISCLOSURE OF MEDICAL INFORMATION
I have filed a charge of discrimination with the Illinois Department of Human Rights (IDHR) related to my
following medical condition(s).
IDHR Charge Number:
Medical Condition(s):
Relevant Date(s):
I hereby permit the Health Care/Social Service Professional identified below, or other authorized medical
professional at the same facility, to complete the Verification of Disability Form and return the completed form to
the IDHR, and to answer any questions IDHR my have regarding the information contained in this form. Please
send all correspondence to the attention of the investigator assigned to my case, or if no investigator is listed below,
to the Fair Housing Unit.
Health Care or Social Service Professional:
Address:
Telephone No.:
(Note to Complainant: if an investigator has not yet been assigned to your case, or if you do not know the name of
your investigator, please leave the following blank.)
Investigator:
I understand that:
IDHR is requesting this information for the purpose of investigating my charge of discrimination
The completed Verification of Disability Form, once returned to IDHR, will become part of IDHR's
investigation file and may be subject to disclosure through subpoena, the Illinois Freedom of Information
Act, or any other lawful means to the parties, the general public, or other governmental agencies, including
the U.S. Department of Housing and Urban Development, local human rights agencies or commissions, or
the Office of Executive Inspector General for the Agencies of the Illinois Governor.
In lieu of signing this Consent and Release for Disclosure of Medical Information, I may submit
information from other sources regarding my identified condition, such as my testimony regarding my
condition, determinations of disability from the U.S. Social Security Administration, Family and Medical
Leave Act forms, or other similar documentation to show that my condition constitutes a disability within
the meaning of the Illinois Human Rights Act.
I have the right to decline to sign this consent and release, and if I do so, IDHR will make a determination
on my charge with other information and evidence obtained during the investigation, including any other
information I submit.
This consent form will expire one (1) year from the date of my signature below and may not be used after
that date.
Signature of Patient (Complainant) or other person
Date
legally entitled to give consent
Patient's Name (Complainant's Name - Printed)
Patient's Date of Birth
Address
City, State, ZIP Code
Date
Witness Signature (Person who can attest to the
identity of the Patient or other person entitled to give
consent)
Witnessed by (Name - Printed)
Verification of Disability (Housing)
2/14
VERIFICATION OF DISABILITY (HOUSING)
Dear Health Care or Social Service Professional:
Your patient (Complainant) has filed a charge with the Illinois Department of Human Rights (IDHR) alleging that
s/he has experienced unlawful discrimination because of the condition identified on the attached Consent and
Release for Disclosure of Medical Information Form. Your patient has identified you as a source of information
regarding the condition and has authorized IDHR to obtain this information from you by signing the attached
Consent Form. In order to help IDHR determine whether the Complainant's condition qualifies as a disability under
the provisions of the Illinois Human Rights Act, please answer the following questions concerning only the
condition or conditions during the relevant dates identified on the Consent Form.
Charge Number:
Complainant:
Condition(s) Identified on the Consent and Release for Disclosure of Medical Information form:
Relevant Dates Identified on the Consent and Release for Disclosure of Medical Information form:
Please Note:
We ask your cooperation in providing the following information and returning it to IDHR.
Your prompt return of this information will help to ensure timely investigation of the
Complainant's discrimination claim.
IDHR is not responsible for any fees or costs
associated with completing this form. If there are fees for a file search and/or copying,
IDHR requests that these fees be waived. If you decline to waive the fees or costs associated
with completing this form, please immediately notify IDHR.
Please direct all
correspondence and inquiries to the Investigator identified on the Consent and Release for
Disclosure of Medical Information form. If no Investigator is identified, please send all
correspondence and inquiries care of the Fair Housing Division.
Name of Investigator Identified on Consent Form (If any):
1.
Can you confirm that Complainant has/had the condition on the relevant dates identified?
Yes
No
2.
Is Complainant's condition a physical, mental, or emotional impairment?
Yes
No
100 W Randolph Street, Suite 10-100, Chicago, IL 60601, (312) 814-6200, TTY (866) 740-3953, Housing Line (800) 662-3942
535 W Jefferson, 1st Floor, Springfield, IL 62702, (217) 785-5100
2309 West Main Street, Marion, IL 62959 (618) 993-7463
www.illinois.gov/dhr
3.
Is Complainant's condition minor?
A minor condition is a condition which is trivial or insubstantial, and is not a disability under the Illinois
Human Rights Act. In determining whether a condition is minor, please note the following:
If the individual is using mitigating measures to address the condition, such as a walking cane,
prosthetic, hearing aid, service animal, or medication, you should assess the condition in its
unmitigated state.
If the individual's condition is episodic or in remission, you should assess the condition in its active
state.
Examples of minor conditions include conditions which are expected to fully heal without any
complications, or non-life threatening conditions which can be successfully treated by ordinary
medications or minimally invasive surgical procedures.
Yes
No
If "Yes", please explain why the condition is minor:
4.
Is Complainant's condition permanent?
Yes
No
If "No", please describe the length of time Complainant's condition is expected to last (be as specific as
possible):
Health Care or Social Service Professional - Please provide the information requested below:
Signature
Address
Printed Name
City, State, ZIP Code
Telephone Number
Date Form Completed
Please return this completed form to:
Illinois Department of Human Rights
100 W Randolph St. Ste. 10-100
Chicago, IL 60601
Please send the form C/O the Investigator named on the Consent form, or if no Investigator is named,
C/O the Fair Housing Division
Verification of Disability (Housing)
2/14
ADVERTISEMENT
Page of 3