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Medical Records Release

Northshore Center for Gastroenterology

Libertyville - Gurnee

Name

First Name

Last Name

Phone Number

(###)

###

####

Date of Birth

YYYY

Date of Medical Records Release Request

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorization of use or disclose of protected health information

I authorize the custodian of records from:

Northshore Center for Gastroenterology

Other __________ to disclose / release the following information from the following dates __________ to the following records:

If selected 'Other' (above), please include location of records along with dates of authorization: (Checkmark all applicable below)

All Records

Laboratory/Pathology Records

X-Ray/Radiology Records

Billing Records

Progress Notes/History and Physical/Summary

Pharmacy/Prescription Records

Other __________

If selected 'Other' (above), please include record type:

Please send records to:

Address of Recipient:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

HIPAA AUTHORIZATION REQUIRED. COMPLETE SIGNATURE FIELD BELOW.

HIPAA AUTHORIZATION. To the extent information in this Secure Form (GI Partners of Illinois, LLC) is protected health information under the Health Insurance Portability and Accountability Act, as amended, and its regulations (“HIPAA”), I authorize the use and disclosure of such information in accordance with this HIPAA AUTHORIZATION. I authorize the use and disclosure of all of the information that I have entered into this Secure Form (“Information”). I am the individual whose Information is included in this Secure Form or I am the personal representative of that individual. The purpose of this disclosure is to allow communication of the Information to a the medical practice from whose website I obtained this Secure Form. The Information will be disclosed to GI Partners of Illinois, LLC in order to facilitate communication between me and the medical practice. I understand that I have the right to revoke this Authorization at any time prior to my submission of this Secure Form by simply not signing this Authorization, but once I sign this Authorization and submit the Secure Form, the Information will be disclosed to Recipients in reliance upon my Authorization. I understand that I am not required to sign this Authorization and that any medical practice making this Secure Form available on its website may not condition my treatment on whether I use this Secure Form to communicate with the medical practice. This Authorization has no expiration date. I understand that the Information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the Recipients and will no longer be protected by HIPAA. I hereby acknowledge that I may print a copy of this Authorization for my records.

Today's Date

YYYY