Illini Pediatrics LLC, DBA Ideal Pediatrics

Release of Records TO Ideal Pediatrics

Patient Name Patient Date of Birth Current mailing address I hereby authorize _______________ to disclose the above-named individual?s health information: Phone number of facility to release information Fax number of facility to release information Dates of Service (if known) Description of Information to be released: (check all that apply)

I understand that the information in my health record may include information relating to communicable disease, Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV), behavioral or mental health, alcohol/drug (substance) abuse or any such related information.

This information may be disclosed to and used by the following individual or organization (receiving the information)

Ideal Pediatrcs- ph. 618-281-4325- 1550 N Main St, Columbia, IL 62236- f. 618-281-8393

Description of the purpose of the use and/or disclosure: (check one)

I understand that this authorization is voluntary and I may refuse to sign this authorization. I further understand that my health care and the payment of my health care will not be affected if I do not sign this form. I may inspect or copy the information to be used or disclosed, and that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient, and may no longer be protected by federal and state privacy regulations. The Clinic may charge a processing fee for this service. This authorization will expire by law 180 days from the date of this authorization unless I otherwise specify. I further understand that I may revoke this authorization at any time by notifying the Health Information Management Department of Ideal Pediatrics,. If I revoke this authorization I must do so in writing and the written revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any actions taken before the receipt of the written revocation.

Name of person completing Policy Addendum Relationship to Patient Today's Date