Welcome to the HIPAA Authorization Form Page for State Agencies
The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), Pub. L. No.
104-191, is a federal statute that provides for the development of uniform national
health information data and privacy standards. Effective April 14, 2003, with very
limited exceptions, privacy regulations promulgated pursuant to HIPAA will prohibit
state agencies that are “covered entities” from disclosing a client’s personal
healthcare information without the client’s written consent on a HIPAA compliant
authorization form.
In an effort to make the process of HIPAA compliance as user-friendly as possible,
we have made authorization forms for each of the agencies impacted by HIPAA available
on this web page.
The HIPAA Privacy Rule will impact the following state
agencies:
Each of the eleven agencies impacted by HIPAA has developed a HIPAA
compliant authorization form tailored to its particular programs.
If you would like to authorize a particular state agency to communicate with your
Legislator or with another party, please download and print the form for that agency.
After completing the entire form, send the form to the agency, per the instructions
listed on the form. Each form will provide the address to which the form must be
sent in order to complete the process.
You must download and print the authorization form for each state agency you would
like to authorize to communicate with any third party.
Agency Authorization Forms
To view PDF documents you will need Adobe's Acrobat Reader. If you do not have the latest reader you can download it here.
Department on Aging
Effective January 1, 2006, qualifying seniors and persons with disabilities may apply for help paying for prescription drugs through the Illinois Cares Rx program (formerly Circuit Breaker Pharmaceutical Assistance and SeniorCare).
Department of Corrections Authorization for Release of Offender Information (8kb PDF)
(Completed Authorization for Release of Offender Information forms should be sent to the Warden of the appropriate DOC facility)
Department Of Revenue
Administrative responsibility for the Circuit Breaker and Pharmaceutical Assistance Programs was transferred from the Department of Revenue to the Department on Aging and Healthcare and Family Services as a result of Executive Order 2004-3, effective July 1, 2004.
