TAB 4207 Sav ESC RELEASE OF PATIENT RECORDS AUTHORIZATION FORM Choyce Smythe Patient's Full Name 1206 White Oak Ln 572413482 Address SSN/Medical Record Number Orland Grove, IL 60097 9/24/2002 City, State, Zip Code Patient's Date of Birth 555-767-2789 I hereby authorize use or disclosure of protected health information about me as described below. Patient's Telephone Number UIC Hospital ) The following specific person/class of person/facility is authorized to use or disclose information about me: 2 ) The following person (class of person) may receive disclosure of protected health information about me: W. GRPH Law Firm His/Her/Its Name 1919 W Taylor St Address Chicago, IL 60612 City, State, Zip Code 3) The specific information that should be disclosed is (please give dates of service if possible): All records between January 21, 2002 and December 31, 2002 UNLESS YOU INITIAL HERE, NO INFORMATION ABOUT ALCOHOL/SUBSTANCE ABUSE, HIV/AIDS, OR MENTAL HEALTH WILL BE DISCLOSED. OYES, DISCLOSE THIS INFORMATION* NO, DO NOT DISCLOSE THIS INFORMATION* LAO 4) I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations. 5) I may revoke this authorization by notifying _UIC Hospital _in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. My purpose/use of the information is for:_ Legal Review 5) 7) This authorization expires on_ 12/31 20_20_, OR upon occurrence of the following event that relates to me or to the purpose of the intended use or disclosure of information about me: FEES FOR COPIES: Federal and state laws permit a fee to be charged for the copying of patient records. THIS FORM MUST BE FULLY COMPLETED BEFORE SIGNING- note that signature is required in two places. * Digitally signed by Felecia William 6/9/2020 9/24/2002 Date: 2020.06.09 16:50:11 -05'00' Date of Birth or SSN Date Signed Signature of Individual (The person about whom the information relates) OR, if applicable Mother Description of Authority to Act Date Guardian's/Personal for the Individual Signature of Guardian* or Representative's Signed Personal Representative of Patient's Estate A copy of this completed, signed and dated form must be given to the Individual or other signator. Official Use Only Log # Processed By Received an ad PG UP LOPG UP RELEASE OF PATIENT RECORDS AUTHORIZATION FORM 134857241 SSN/Medical Record Number Laryn Owens Patient's Full Name 12/26/1967 Patient's Date of Birth 1206 White Oak Ln 555-767-2789 Address Patient's Telephone Number Orland Grove, IL 60097 City, State, Zip Code I hereby authorize use or disclosure of protected health information about me as described below. The following specific person/class of person/facility is authorized to use or disclose information about me: UIC Hospital 2) The following person (class of person) may receive disclosure of protected health information about me: W. GRPH Law Firm His/Her/Its Name 1919 W Taylor St Address Chicago, IL 60612 City , State, Zip Code 3) The specific information that should be disclosed is (please give dates of service if possible): All records between January 21, 1991 and December 31, 2002 UNLESS YOU INITIAL HERE, NO INFORMATION ABOUT ALCOHOL/SUBSTANCE ABUSE, HIV/AIDS, OR MENTAL HEALTH WILL BE DISCLOSED . OYES, DISCLOSE THIS INFORMATION* NO, DO NOT DISCLOSE THIS INFORMATION* LA.O 4) I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations. 5) I may revoke this authorization by notifying_ UIC Hospital _in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. 6) My purpose/use of the information is for: . Legal Review 7) This authorization expires on 12/31 2 intended use or disclosure of information about me: 20 20 , OR upon occurrence of the following event that relates to me or to the purpose of the FEES FOR COPIES: Federal and state laws permit a fee to be charged for the copying of patient records THIS FORM MUST BE FULLY COMPLETED BEFORE SIGNING- note that signature is required in two places.* dang Uwere Digitally signed by Felecia Williams Date: 2020.06.09 16:50:11 -05'00' 6/9/2020 Signature of Individual 12/26/1967 (The person about whom the information relates) Date Signed OR, if applicable Date of Birth or SSN Signature of Guardian* or Personal Representative of Patient's Estate Date Guardian's/Personal Representative's Signed Description of Authority to Act for the Individual A copy of this completed, signed and dated form must be given to the Individual or other signator. Official Use Only Received Processed By Log # S LOC ESC