Morris Therapy | Morris Medical Record Request | depression | counseling | Institute for Personal Development | IL |

http://www.ipd.md/userfiles/1867/pdf/Auth_to_Release_2011.pdf

IPD requires that an IPD Authorization to Release Information form be completed by the patient prior to our releasing, or requesting, medical records on the patient’s behalf.

Please select, print and complete this authorization form.

There are three very important items that must be done to complete the form.

1. Please sign and date the form where it says “signature of client.”
2. A witness MUST be present when the form is signed and that witness MUST sign the form and date it for it to be valid. Have the witness sign it where it says “signature of witness.”
3. Write in the line after “for the purpose of:” the reason why medical records are being requested.

For your convenience, you can fax the signed authorization to IPD’s confidential medical records fax number:

Joliet-   815-725-7166
Morris- 815-941-0308
Ottawa- 815-941-0308
Romeoville- 630-226-9475
Oak Brook- 815-941-0308
Chicago- 815-941-0308

**There is a standard processing fee of $30.00 for any medical records that are released**