Authorization to Disclose/Obtain Information - dhs state il 2026

1. Click ‘Get Form’ to open it in the editor.
2. Identify whether you are authorizing the disclosure, obtaining, or both. Fill in the name of the Hospital/Agency/Individual responsible for this action.
3. Select the specific information you wish to disclose or obtain by checking the relevant boxes, ensuring you only select what is necessary.
4. Complete the individual's name, date of birth, social security number, and any aliases to ensure accurate identification.
5. Indicate the purpose for which this information is needed by checking the appropriate box.
6. Specify how you would like the information disclosed (e.g., mail, phone) and note any restrictions if applicable.
7. Fill in the name and address of the agency or individual from whom you are obtaining information.
8. Set a calendar date for when this authorization will expire; this is crucial for compliance.
9. Ensure all required signatures are obtained from individuals aged 12 and older or their guardians as necessary.

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