I authorize _____________The People’s Clinic____________ of 1000 N. Lake, Chicago, Illinois (Agency/Person) (Address) to release_________________________ Laboratory Results_________________________ (State specific nature of information to be disclosed)
about_________ Jane Doe__________ October 12, 1970___1000 N. Street, Aurora, Illinois (Patient) (Birth date) (Address)
for the purpose of_______ notification to John Doe_________________________________
This consent is valid until May 9, 2015. (Date)
I understand:
I have the right to inspect and copy the information to be disclosed. I have the right to revoke this consent at any time.
Revoking this consent shall have no effect on disclosures made before the withdrawal of consent.
The information obtained as a result of this release may not be re-disclosed unless I specifically consent to it.
It has been explained to me that if I refuse to consent to this release of information, the following are the consequences (specify):
N/A
____ Jane Doe_______________ __ 1000 N.Street, Aurora, Illinois___ _ May 9, 2014________ Signature of Patient Address Date
___________________________ ____________________________ ______________________ Signature of Witness Address Date
* Recipient and Parent/Guardian must sign if recipient is under the age of eighteen*
Part Two
The first step that I would take on noticing the missing chart would be to assess the loss. First of all, I would check if any other records pertaining to that particular patient are missing. Then I would proceed to value the level of information that was contained within the chart and its
