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(Person signing authorization)
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.
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.
This field is not part of the form submission.
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