The purpose of this disclosure is to provide to Access DuPage information required to determine my eligibility to participate in the Access DuPage Program, to arrange medical services through Access DuPage, and/or facilitate my participation in pharmaceutical programs by Access DuPage. Therefore, I hereby authorize you to release any medical and non-medical information in your possession, custody or control regarding the individuals listed below pursuant to this authorization.
I, the undersigned, hereby authorize any and all physicians, hospitals, clinics, other medical-related facilities, insurance companies, and employers to release to Access DuPage any records and information requested by Access DuPage for the Access DuPage applicant listed below.
Please release this information to Access DuPage, 511 Thornhill Drive Suite C, Carol Stream, IL 60188. Such information may be used by the employees of Access DuPage, as well as medical providers, pharmaceutical company representatives, and representatives of other agencies providing medical benefits. I consent to disclosure of my personal health information to these parties, but only as needed to perform regular operations.
I understand that I may revoke this authorization at any time by requesting such to Access DuPage in writing at the above address. This authorization shall remain valid for one year from the date signed below and I know I may request a copy of it. A copy of this shall be considered as valid as the original.