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It specifies the approximate treatment dates, the method of release (verbal, paper copy, CD/electronic, fax, secure email, pickup, or mail), and the types of records authorized, including mental health, substance use, public health services, and HIV. It sets the purpose of disclosure, authorization expiration, key privacy notices, and required signatures, then provides submission instructions to the health department.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/release-information-form-english/283889/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/release-information-form-english/283889.png","ImageObject",442,249,{"name":88,"@type":89},"Aldword","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information does this form require from the client?","Question",{"text":109,"@type":110},"It requires the client’s legal name, address, city/state/ZIP, phone number, and date of birth, plus details about the treatment dates and authorized records.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What records can be authorized for release?",{"text":114,"@type":110},"The form allows check-off selections across services such as mental health, substance use, public health services, and HIV, and it specifies record types like assessment/treatment plans, progress notes, discharge summaries, lab results, and related documents.",{"name":116,"@type":107,"acceptedAnswer":117},"When does the authorization expire and what privacy rules apply?",{"text":118,"@type":110},"Authorization typically expires one year from the signature date unless another date is noted. The form also outlines rights to inspect and copy records, revocation in writing, limits on re-disclosure, HIPAA and Illinois privacy/security standards, and special protections such as 42 CFR Part 2 for substance use records.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283889,1791384394,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},2336478940917,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","| CLIENT INFORMATION: |  |  |  |\n| --- | --- | --- | --- |\n| Client’s Legal Name: (First, Middle, Last) |  |  | Date of Birth (Month, Day, Year)/ / |\n| Address: |  |  |  |\n| City | State: | Zip Code: | Phone Number:\u003Cbr>( ) - |\n\n\n| RELEASE INFORMATION FROM: |  |  |  |\n| --- | --- | --- | --- |\n| Person/Agency Name: |  |  |  |\n| Address: |  |  | Phone Number:\u003Cbr>( ) - |\n| City | State: | Zip Code: | Fax Number:\u003Cbr>( ) - |\n\n\n| RELEASE/SEND INFORMATION TO: |  |  |  |\n| --- | --- | --- | --- |\n| Person/Agency Name: |  |  | Attention: |\n| Address: |  |  | Phone Number:\u003Cbr>( ) - |\n| City | State: | Zip Code: | Fax Number:\u003Cbr>( ) - |\n\n\n| DATES OF TREATMENT: |\n| --- |\n| Approximate Dates of Treatment. Must be listed as MM/DD/YYYY to be valid (Current, Present, All are not acceptable):\u003Cbr>/ / To / / or specific date: / / |\n\n\n| METHOD OF RELEASE: (Check all that apply): *Please allow 30 days for processing |\n| --- |\n| Type: Verbal disclosure Paper copy of record CD/Electronic\u003Cbr>Method:\u003Cbr>Fax \\#: ( ) -\u003Cbr>Electronically/Secure Email Address:  \u003Cbr>Pick up at: Wheaton Addison Lombard Westmont\u003Cbr>Mail to address above |\n\n\n| INFORMATION TO BE RELEASED: |\n| --- |\n| Include information for the following services: (Check all that apply) Mental Health (MH)\u003Cbr>Substance Use\u003Cbr>Public Health Services\u003Cbr>HIV |\n| And specify the records authorized for release: (Check all that apply)\u003Cbr>Assessment/Evaluation/ Treatment Plans Progress Notes Psychiatric Evaluation/Progress Notes\u003Cbr>Discharge Summary Medication List Lab Results/Reports\u003Cbr>Appointment History Immunization Records Dental Records (Notes & X-Rays)\u003Cbr>STI HIV Tuberculosis\u003Cbr>Billing Information Benefit Documents Legal Forms\u003Cbr>Other (describe) :  \u003Cbr>Abstract – Documents completed within the last year or the last document that was completed if the date is longer than a year. Documents included: IM+CANS, Discharge summary, Mental Health Assessment, Treatment Plan, Psychiatric Evaluation, Psychiatric Progress Note. |\n\n\n| PURPOSE OF RELEASE: (Check all that apply): |\n| --- |\n| Continuity of Care Coordination of Care/ Services Personal Use/Review\u003Cbr>Legal Social Security Appeal/Disability Determination\u003Cbr>Emergency Contact Only Research Purpose Treatment Scheduling\u003Cbr>Other (describe):   |\n\n\n| AUTHORIZATION EXPIRATION DATE: |\n| --- |\n| This authorization will expire one year from the date of signature unless a different date is noted: / / |\n\n\n| IMPORTANT INFORMATION: |\n| --- |\n| • A fee may be charged for the cost of processing this request.\u003Cbr>• This authorization may be revoked in writing at any time, by submitting the designated revocation form to DCHD Medical records, for more information [visit our website](visit our website www.dupagehealth.org. Revocation will)[ www.dupagehealth.org](visit our website www.dupagehealth.org. Revocation will)[.](visit our website www.dupagehealth.org. Revocation will)[ Revocation will](visit our website www.dupagehealth.org. Revocation will) not apply to information that has already been released.\u003Cbr>• You have the right to inspect and copy the information to be disclosed.\u003Cbr>• I also understand that information in my health record which may be related to behavioral health, sexually transmitted infection/disease, AIDS or HIV, domestic violence, alcohol, or drug use, and/or genetic testing will not be disclosed without my specific consent.\u003Cbr>• My providers will use secure methods that meet the privacy and security standards of both the Health Insurance Portability and Accountability Act (HIPAA) and Illinois law, to exchange my health information.\u003Cbr>• Re-disclosure of information is prohibited unless the person who consented to the disclosure specifically permits such re-disclosure in writing.\u003Cbr>• DuPage County Health Department will not restrict treatment if you choose to not sign this authorization. I understand it may result in a delay of service, limited treatment coordination, inability to release information and/or limited continuity of care.\u003Cbr>• 42","cbCaidS2ztDJkJz4","https://ap.wps.com/l/cbCaidS2ztDJkJz4","pdf",291952,"English","# Client Information\n# Release Information From\n# Release/Send Information To\n# Dates of Treatment\n# Method of Release\n# Information to Be Released\n# Purpose of Release\n# Authorization Expiration Date\n# Important Information\n# Signatures\n# Submitting Your Request\n# For Internal Use Only","[{\"question\":\"What information does this form require from the client?\",\"answer\":\"It requires the client’s legal name, address, city/state/ZIP, phone number, and date of birth, plus details about the treatment dates and authorized records.\"},{\"question\":\"What records can be authorized for release?\",\"answer\":\"The form allows check-off selections across services such as mental health, substance use, public health services, and HIV, and it specifies record types like assessment/treatment plans, progress notes, discharge summaries, lab results, and related documents.\"},{\"question\":\"When does the authorization expire and what privacy rules apply?\",\"answer\":\"Authorization typically expires one year from the signature date unless another date is noted. The form also outlines rights to inspect and copy records, revocation in writing, limits on re-disclosure, HIPAA and Illinois privacy/security standards, and special protections such as 42 CFR Part 2 for substance use records.\"}]","Release Information Form - English | PDF",1789621509]