IN THE CIRCUIT COURT OF ________________________COUNTY, ILLINOIS In the Matter of the Petition of ________________________ For appointment of Confidential Intermediary ) ) ) ) ) ) No. _______________________ ORDER FOR APPOINTMENT OF CONFIDENTAL INTERMEDIARY This cause, having been heard upon the Petition filed for the appointment of a Confidential Intermediary pursuant to the Adoption Act at 750 ILC 50/18.3a, and the Court having considered the contents thereof, and being fully advised in the premises, finds: 1. That the Petitioner is: an adopted person 21 years of age or over; or a "surrendered person" 21 years of age or over; or the adoptive parent or legal guardian of an adopted or surrendered person under the age of 21; or a birth parent of an adopted or surrendered person 21 years of age or over; or surrendered person (strike as applicable); or an adult birth sibling of a adopted or surrendered person who is 21 years of age or over; or an adult child, grandchild, adoptive parent, legal guardian, or surviving spouse of a deceased adopted or surrendered person who is 21 years of age or over; or an adult sibling of a deceased birth parent whose surrendered child is 21 years of age or over; or 2. That the Petitioner seeks to: exchange medical information with one or more mutually consenting biological relatives of the adopted or surrendered person; and/or obtain identifying information about one or more mutually consenting biological relatives of the adopted or surrendered person; and or arrange contact with one or more mutually consenting biological relatives of the adopted or surrendered person. Obtain identifying information that would have been found on the adopted person's original birth certificate, if the adopted person was born prior to January 1, 1946 and if the certificate was not found or the petitioner received the non-certified copy of the original birth certificate which omits the name of the birth parent; or Obtain identifying information that would have been found on the adopted person's original birth certificate, if the adopted person was born after January 1, 1946, and if the certificate was not found. American LegalNet, Inc. www.FormsWorkFlow.com 3. That because the Petitioner is not: · an adult adopted or surrendered person 21 years of age or over; or · an adoptive parent or legal guardian of an adopted or surrendered person under the age of 21; or · a birth parent of an adopted or surrendered person who is 21 years of age or over · the Court finds that disclosure is of greater benefit than non disclosure. (Strike if inapplicable) IT IS HEREBY ORDERED: 1. That is appointed as a Confidential Intermediary to act in accordance with the mandates in Section 18.3a of the Adoption Act (750 ILCS 50/18.3a); 2. That the Confidential Intermediary shall have access to: 1. Vital Records maintained by the Illinois Department of Public Health and its local designees or a comparable public entity that maintains vital records in another state in accordance with that state's laws; 2. Court records which relate to the adoption or the identity and location of an adopted or surrendered person, of an adult child or surviving spouse of a deceased adopted or surrendered person, or which relate to the location and identity of a birth parent, birth sibling, or the sibling of a deceased parent; 3. Records and documents as described in 3.a and 3.b regarding a surrendered person when the Petitioner is an adult child of a deceased surrendered person; 3. The Confidential Intermediary shall not have access to: 1. Personal health information protected by the Standards for Privacy of Individually Identifiable Health Information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA); 2. Medical Records; 3. Financial Records; 4. Credit Records; 5. Banking Records; 6. Home Studies; 7. Education Records; 8. Attorney File Records; and 9. Except as provided in paragraphs 5 and 6, other Personal Records; 4. The public or private adoption agency shall only disclose to the Confidential Intermediary the full name, date of birth, place of birth, last known address and last known telephone number of the sought after relative, or if applicable, of the children or siblings of the sought after relative; 5. In addition to the information specified in paragraph 5 of this Order, adoption agencies shall provide the Confidential Intermediary with any statement indicating a desire by the surrendering birth parent to have identifying information shared or not shared. In the event a sought after birth parent has made a clear statement of intent pursuant to 18.3 to not have identifying information shared, the American LegalNet, Inc. www.FormsWorkFlow.com Confidential Intermediary shall discontinue the search and inform the petitioner of the sought after birth parent's intent. 6. An adoption agency shall disclose to Confidential Intermediary medical information about an adult adopted person or a minor adoptee only if the adult adopted person or the adoptive parent of an adopted minor has signed a written HIPAA authorization for disclosure of personal medical information. The medical information disclosure under this paragraph 7 is limited to medical information about the adopted person from birth through the date of the adoption; 7. The Illinois Adoption Registry shall release to the Confidential Intermediary all information described in Section 18.3a (i) of 750 ILCS 50 as amended; 8. The Illinois Adoption Registry shall release to the Confidential Intermediary information regarding the date the adoption was finalized and the county in which the adoption was finalized; 9. The Confidential Intermediary will act in accordance with the Adoption Act and 750 ILCS 50/18.3a and will take an oath of office as provided in section (j) of the statute as a condition of his/her appointment, and the appointment of the Intermediary shall be effective upon execution of said oath, which the Intermediary shall, upon execution, file with the Clerk of the Court. 10. This case is set for status on ___________ at _____ in Courtroom ______. The Confidential Intermediary shall submit an interim or final written report prior to said date. 11. All documents, reports, and other written material submitted to the court shall be filed herein pursuant to the provision of 750 ILCS 50/18.3a, and the records maintained by the Circuit Clerk shall be impounded as provided in the Adoption Act. ENTERED: _______________________