Illinois Department on Aging Authorization for Release of Information

Illinois Department on Aging Authorization for Release of Information

Participant Name*

Address*

Phone*

Email*

Social Security or ID Number*

Date of Birth*

Illinois County of Residence*

Requester Name

If you are not the Applicant/Participant, attach the appropriate legal documentation assigning you as the

Applicant/Participant’s Legal Representative.

Requester Phone

Requester Email

Requester Address

Relationship to Participant

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Information Requested*

List the information you are requesting (e.g. specific type of information, specific time frames, specific provider, etc.)

Purpose of Authorization*

List why you are authorizing the release of this information (e.g.: proof of services, possible litigation, etc.)

Send the Information to:*

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Name and Address of Person or Organization

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Signature

Release Authorization: I, the Applicant/Participant or the Legal Representative listed above, authorize the Illinois Department on Aging (IDoA) to release the requested information to the individual or entity listed for the purposes described. I understand that this authorization expires one year from the Date of Authorization and that I may revoke this authorization at any time by sending a written notification to IDoA at Aging.Subpoenas.Authorizations@illinois.gov. If I revoke the Authorization, it will not affect any information released before the revocation was received by IDoA.

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