Serving Illinois. Your appointment must be handled by an Illinois-commissioned notary.

HIPAA Authorization - Illinois

Illinois · Fillable PDF · Free

Federal privacy law (HIPAA) limits who doctors, hospitals, and insurers can talk to about you. This authorization lets the people you name receive your health information so they can help you, even before they need to act as your agent. Federal privacy law (HIPAA) limits who doctors, hospitals, and insurers can talk to about you.

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Who this form is for

Illinois residents and families reviewing hipaa authorization instructions.

What you'll need

Read the original packet’s instructions and complete only the fields that apply.
Bring acceptable identification and follow the packet’s signature and witness instructions.

How to complete it

Your information (Page 1) Enter your name, date of birth, and address.
Who may receive it (Page 1) Name each person who may receive your health information, such as your agents under your powers of attorney or family members.
What and for how long (Pages 1–2) Choose what may be released and when this authorization expires. Initial each type of specially protected record you want included.
Sign before a notary (Page 2) Illinois requires a witness who can confirm your identity before mental health records are released. The notary acknowledgment serves that purpose and makes hospitals and insurers far more likely to accept the form. Bring a current, government-issued photo ID.

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These forms are a free convenience, not legal advice. First Choice Mobile Notary & Apostille is not a law firm. Consult an attorney licensed in the relevant state for legal questions.

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