Print Form Authorization for Access to Records of Court Proceedings IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION Clear Form (11/15/11) CCCO 0816 AUTHORIZATION FOR ACCESS TO RECORDS OF COURT PROCEEDINGS Pursuant to the Mental Health and Developmental Disabilities Confidentiality Act The Court's case file number containing this information is _______________________________________ unknown to me. I, (PLEASE PRINT NAME) ________________________________________, authorize the Clerk of the Circuit Court of Cook County to release information maintained in a court proceeding filed under the provisions of the Illinois Mental Health and Developmental Disabilities Code, 405 ILCS 5/1, et seq., and concerning a recipient1 of mental health or developmental disability services, to (PRINT RECIPIENT'S NAME) _______________________________________________________________________________________ The information is to be released to me another (PRINT NAME): ______________________________________________________ The person, facility or agency receiving this information may inspect and copy court records containing such information. The purpose of this disclosure is: _______________________________________________________________________________ The expiration date of this authorization is: ____________________________ None. (if "none" is checked, the information will be released only on the date which this authorization is received by the Clerk or directed by the Court.) My relationship to the recipient is: Recipient Parent/Guardian of recipient under 12 years old Parent/Guardian of recipient between 12 and 18 years old, neither recipient nor service provider objects Guardian of recipient over 18 years old Attorney/Guardian ad litem of recipient between 12 and 18 years old authorized by a court or administrative hearing officer (attach copy of order/authorization) Agent pursuant to power of attorney for health care or property (attach copy of power of attorney) Attorney-in-fact pursuant to declaration for mental health treatment (attach copy of declaration) It has been explained to me that a refusal to authorize release of this information will have the following consequences: None (Specify) ________________________________________________________________________________________ Other instructions: _________________________________________________________________________________________ ____________________________________________________________________________________________________________ I understand this authorization may be revoked2 at any time for any reason, and any such revocation will be effective only upon delivery of a written revocation to the Clerk of the Circuit Court of Cook County, County Division, Richard J. Daley Center, Room 1202, Chicago, Illinois 60602-1317. Under penalties provided by 735 ILCS 5/1-109, the person authorizing disclosure certifies that the statements set forth in this instrument are true and correct, and the witness certifies that said person is known to him/her and is the person who executed this instrument, and the person receiving information certifies s/he is the person so authorized. FOR CLERK'S OFFICE USE ONLY GRANTED DENIED ITEMS RELEASED: _____________________________________________________________ Signature of person authorizing disclosure Date _____________________________________________________________ Signature of witness Print name and address of above witness Date _____________________________________________________________ _____________________________________________________________ Signature of person receiving information 1 ___________________________________________ ___________________________________________ ___________________________________________ PHOTO ID.: _______________________________ ID.: ____________________________________ ID.: ____________________________________ CLERK: _________________________________ Date Recipient means a person who has received or is receiving mental health or developmental disabilities treatment or habilitation. 405 ILCS 5/1-123. 1 Any such revocation shall have no effect on disclosures made prior thereto. 740 ILCS 110/5(c). NOTICE TO RECEIVING AGENCY, FACILITY OR PERSON: No person or agency to whom any information is disclosed under this section may re-disclose such information unless the person who consents to the disclosure specifically consents to such disclosure. 740 ILCS 110(d). PLEASE TAKE FURTHER NOTICE: Except as otherwise provided by law, records and communications shall remain confidential after the death of a recipient and shall not be disclosed unless the recipient's representative, as defined in the Probate Act of 1975 (755 ILCS 5/1-1, et seq.) and the therapist consent to such disclosure or unless disclosure is authorized by court order after an in camera examination (by the court) and upon good cause shown. 740 ILCS 110/5(e). DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS