Authorization to Release
Immunization Records
Illinois Department of Public Health, Immunization Section
I-CARE: Illinois Comprehensive Automated Immunization Registry Exchange
v2 May 2021
Printed by Authority of the State of Illinois 5/21
IOCI 22-275
INSTRUCTIONS:
1. Complete ALL portions of this form.
2. Send completed form with signature via fax to 217-524-0967 or via email to: dph.icare@illinois.gov
3. If you have any questions, call the Immunization Section at 217-785-1455 or email: dph.icare@illinois.gov
Patient’s Name:
first name last name middle initial
Date of Birth (month, day, year): Previous Name(s):
Parent or Guardian (if under eighteen (18)):
Contact Number: Request Date:
Person, agency, or facility to receive records:
Mailing Address (number and street):
City: State: ZIP Code:
E-mail:
Fax Number:
Choose a method of delivery of records by checking the corresponding box below:
Fax E-mail U.S. Mail
This Authorization remains in effect:
From the date of this Authorization until
Until the Illinois Department of Public Health fulfills the request or 60 days from the date of this Authorization is signed,
whichever occurs earlier.
(not longer than 60 days).
I hereby authorize the Illinois Department of Public Health to release the immunization records of the Patient identified above contained in I-CARE
(“Immunization Records”), which may include, without limitation, name, address, social security number, date of birth, race and ethnicity demographics,
mother’s maiden name, types and dates of immunizations, name and address of the provider administering each dose, any and all adverse reactions to any
immunization, insurance coverage information and existence of any medical or religious exemptions of the above for which data is being collected.
I understand that:
• The information disclosed pursuant to this Authorization may be subject to redisclosure by the Recipient and may no longer be protected by
applicable federal or Illinois law. The Illinois Department of Public Health cannot guarantee that the Recipient will not re-disclose the immunization
information provided to a third party. The third party may not be required to abide by this Authorization or applicable federal or Illinois law governing
the use and disclosure of health information.
• I have the right to revoke this Authorization in writing at any time. The revocation will be effective immediately except to the extent that the Illinois
Department of Public Health acted in reliance on this Authorization before it received the written notice of revocation.
• This Authorization will remain in effect until the term of the Authorization expires or a written notice of revocation is received by the Illinois
Department of Public Health.
• I may be contacted by the Illinois Department of Public Health for additional information if the records of the Patient identified above cannot be
identified based on the information provided.
• The Illinois Department of Public Health may require identity verification utilizing a secure and encrypted electronic transmission to me, as the patient
identified above.
By my signature below (or by typing my name below), I hereby attest that (i) I am the Patient identified above or the parent or legal guardian of the
Patient identified above, (ii) I authorize the release of the Immunization Records for the Patient identified above to the Recipient specified above and (iii)I
fully understand the meaning of this authorization. A photo static or facsimile copy of this authorization is valid as the original.
(Signature of patient/parent or legal guardian)
(Relationship to patient) (Date)
click to sign
signature
click to edit
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