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AUTHORIZATION TO RELEASE PROTECTED HEALTH …

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION174-0319 ROIP atient Name: Date of Birth: Other Names: Last 4 digits of SSN: MRN: I authorize: Carle - HEALTH Information Management3310 Fields South DriveChampaign, IL 61822 To Send to: (Name of HEALTH Care Facility, Physician, Individual, or Agency, etc.)

• I understand that my medical record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), treatment for alcohol and/or substance abuse, and genetic testing results. A separate special authorization must be completed to release mental health records.

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