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| | 10400HB4845ham001 | - 2 - | LRB104 17026 JRC 34489 a |
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| 1 | | health care records must be released upon the written request |
| 2 | | of a person, who is considered to be a personal representative |
| 3 | | of the patient for the purpose of the release of an |
| 4 | | incapacitated patient's health care records, in one of these |
| 5 | | categories: |
| 6 | | (1) the incapacitated person's spouse; or |
| 7 | | (2) if there is no spouse, any one or more of the |
| 8 | | following: |
| 9 | | (A) an adult child of the incapacitated person; |
| 10 | | (B) a parent of the incapacitated person; or |
| 11 | | (C) an adult sibling of the incapacitated person. |
| 12 | | (b) Health care facilities and practitioners are |
| 13 | | authorized to provide a copy of an incapacitated patient's |
| 14 | | records based upon a person's payment of the statutory fee and |
| 15 | | signed Authorized Relative Certification, attesting to the |
| 16 | | fact that the person is authorized to receive such records |
| 17 | | under this Section. |
| 18 | | (c) Any person who, in good faith, relies on a copy of an |
| 19 | | Authorized Relative Certification has the same immunities from |
| 20 | | criminal and civil liability as those who rely on a power of |
| 21 | | attorney for health care as provided in Section 30 of the |
| 22 | | Health Care Surrogate Act or any other State law. |
| 23 | | (d) Upon request for records of an incapacitated person, |
| 24 | | the named authorized relative shall provide the facility or |
| 25 | | practitioner with a statement of a treating health care |
| 26 | | provider that the person is incapacitated as defined in the |
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| | 10400HB4845ham001 | - 3 - | LRB104 17026 JRC 34489 a |
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| 1 | | Illinois Power of Attorney Act and a certification in |
| 2 | | substantially the following form: |
| 3 | | AUTHORIZED RELATIVE CERTIFICATION |
| 4 | | I, (insert name of authorized relative), certify that I am |
| 5 | | an authorized relative of (insert name of incapacitated |
| 6 | | person). (A statement of the treating health care provider |
| 7 | | must be attached.) |
| 8 | | I certify to the best of my knowledge and belief that no |
| 9 | | guardian has been appointed for the incapacitated person, that |
| 10 | | no agent was authorized to act for the incapacitated person |
| 11 | | under a power of attorney for health care, and the |
| 12 | | incapacitated person has not specifically objected to |
| 13 | | disclosure in writing. |
| 14 | | (CHECK ONE) |
| 15 | | ..... I certify that I am the spouse of the incapacitated |
| 16 | | person. |
| 17 | | ..... I certify that there is no spouse and my |
| 18 | | relationship to the incapacitated person is (circle one): |
| 19 | | (1) An adult child of the incapacitated person. |
| 20 | | (2) A parent of the incapacitated person. |
| 21 | | (3) An adult sibling of the incapacitated person. |
| 22 | | I certify that I am seeking the records as a personal |
| 23 | | representative who is acting in a representative capacity and |
| 24 | | who is authorized to seek these records under Section |
| 25 | | 8-2001.10 of the Code of Civil Procedure. |
| 26 | | This certification is made under penalty of perjury. |