Authorization to Release Information

Please correct the errors described below.

I authorize the use and/or disclosure of my protected health information as described below. I understand this authorization is voluntary and made to confirm my direction. I understand that if the persons or organizations I authorize to receive and/or use the protected health information, described below are not health plans, covered health care providers or health care clearinghouses subject to federal health information privacy laws, they may further disclose my protected health information and it may no longer be protected by federal health information privacy laws.

to release my protected health information to:

At: The Foot & Ankle Center Of Illinois 2921 Montvale Drive Springfield, IL 62704

Fax Number: (217) 785-2715

I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance on this authorization, by submitting a notice to the facility Privacy Officer at 2921 Montvale Drive, Springfield, IL 62704. Unless revoked, this authorization will expire one year from the date of the signature, unless otherwise specified.

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

(Patient, parent if minor child, or legal guardian)


Your information will be encrypted.