аЯрЁБс>ўџ 9;ўџџџ8џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅС#` јПSbjbj\.\. 4(>D>DSџџџџџџЄюююююююц ц ц ц , ‡ь2 |Ў Ў Ў Ў Ў "а ф $shл”,юо Ў Ў о о ,ююЎ Ў A’’’о юЎ юЎ ’о ’’юю’Ў & 0тЩTжЪц є ’W0‡’o ro’oю’t№ „t ^’в L Р№ № № ,,|№ № № ‡о о о о фц ц ююююююџџџџ SOUTHERN ILLINOIS UNIVERSITY AUTHORIZATION FOR RELEASE OF CONFIDENTIAL MEDICAL INFORMATION I, ___________________________________ hereby give my consent to ________________________________________, (Name of Patient or Authorized Agent) (Name of Health Care Facility, Physician, Agency, etc.) ____________________________________________________________ to release to University Risk Management, (Address) Southern Illinois University, 1301 W. Chautauqua, MC 6829, Carbondale, IL 62901, all information contained in the medical record of _____________________________________ __________________, relating to medical care and (Patient’s Name) (Birth Date) treatment provided to the above named patient from ________________ to _________________ for the purpose of (Date) (Date) ________________________________________________________________________________________________ (e.g., investigation of claim, disclosure to attorney, disclosure to insurance company, etc). The type and amount of information to be used or disclosed is as follows: (include dates where appropriate)  FORMCHECKBOX  problem list  FORMCHECKBOX  medication list  FORMCHECKBOX  list of allergies  FORMCHECKBOX  immunization record  FORMCHECKBOX  most recent history and physical  FORMCHECKBOX  most recent discharge summary  FORMCHECKBOX  laboratory results from (date) _______________ to (date) ________________  FORMCHECKBOX  x-ray and imaging reports from (date) _______________ to (date) ________________  FORMCHECKBOX  consultation reports from (doctor’s name) _______________________________  FORMCHECKBOX  entire record from (date) _______________ to (date) ________________ Other:______________________________________________________________________________________________ Special Instructions: ___________________________________________________________________________________________________ To the extent applicable, I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. 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 University Risk Management. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition: ______________________. If I fail to specify an expiration date, event or condition, this authorization will expire in six months. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. 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