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2. I,*

   (Person signing authorization)

3. hereby authorize*

   (Healthcare Provider)

5. to furnish the following information to an agent of the City of Carbondale Police Department, 501 S. Washington Street, Carbondale, Illinois 62901 and/or the Jackson County Illinois State's Attorney, 1001 Walnut Street, Murphysboro, Illinois 62966.

7. Purpose of Disclosure:*

   1. Request of Individual

   1. Other
8. Other:
10. Patient Name*
11. Date of Birth*
12. Date of Treatment
14. Specific Information to be Released*

    1. Discharge Summary
    2. History and Physical
    3. Emergency Report
    4. Operative Report
    5. Pathology Report

    1. Laboratory Report
    2. Radiology Report
    3. Itemized Bill
    4. Other
15. Explain Other

17. I understand that this authorization includes disclosing information regarding mental health, developmental disability, sexually transmitted disease, alcohol and/or drug abuse services, and HIV/AIDS test results, including but not limited to examination, diagnosis, evaluation, treatment, or rehabilitation.

    I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Health Information Department of Southern Illinois Healthcare. I understand that the revocation will not apply to information that has already been released in response to this authorization. If I fail to specify an expiration date, event, or condition this authorization will expire in 6 months, or the date inserted below.

    I understand that the information (excluding mental health information) that is being disclosed under this authorization, may be subject to re-disclosure by the recipient and no longer be protected under the Health Insurance Portability and Accountability Act.

    I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure healthcare treatment.

    I agree that a photocopy of this authorization is as valid as the original.

19. Date
21. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
23. Electronic Signature of Patient/Legal Representative
25. If signed by other than the patient, please indicate relationship and why patient did not sign
27. Officer Name & ID #
28. Date
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field