Print Form Clear Form Order for Release of Medical Records IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS DEPARTMENT OF JUVENILE JUSTICE AND CHILD PROTECTION CHILD PROTECTION DIVISION In the Interest of (8/29/08) CCJP 0674 _________________________________________________ } 5333 Juvenile No. ________________________________ Calendar ___________________________________ ORDER FOR RELEASE OF MEDICAL RECORDS THIS MATTER COMING to be heard before the Honorable _______________________________________, the parties being present and/or represented by counsel, and Court being fully advised of the premises, pursuant to 20 ILCS 301/30-5, 42 C.F.R. 2.64 (the Alcoholism and Other Drug Abuse and Dependency Act), 42 USC 290 dd-2 et seq. 45 C.F.R. 160.103, 45 C.F.R. 160.203, 45 C.F.R. 164.104, 45 C.F.R. 512 (the Health Insurance Portability and Accountability Act of 1996), 740 ILCS 110/1 et seq. (The Illinois Mental Health and Developmental Disabilities Confidentiality Act), and 705 ILCS 405/2-18(e) (the Juvenile Court Act): IT IS HEREBY ORDERED THAT: __________________________________________ shall release any and all medical records, including toxicology reports, reasonable testimony, any and all reports, data, notes or memoranda, photographs, x-rays, and all other documents written or otherwise recorded, regarding the services, counseling, admission, discharge, treatment and recommendations of _____________________________________________________________________, date of birth, _______________ seen on or about _________________________________ within twenty-eight (28) days, to: ______________________________________________________________________________________ __________________________________________________________________________________________________________________________________ The records are requested for the sole purpose of the legal proceedings pending in Juvenile Court. The disclosure is limited to the parties of the above-captioned cause, all of whom have a need for the information contained within the records. Since Juvenile Court proceedings are confidential by nature, disclosure of information will be limited to the court, parties present in court and parties permitted access to confidential court files. Furthermore, other ways of obtaining the records are not available and/or would not be effective. Disclosure of this information is necessary in connection with the investigation of abuse/neglect/dependency of the above captioned minor(s). Also, the public interest and need for disclosure outweigh any potential injury to the patient, physician-patient relationship and the treatment or services. This order is based on a showing of good cause and also because Juvenile proceedings are confidential in nature. This order shall expire upon the closing of said juvenile court proceedings or ___________________, whichever is sooner. Atty. No.: _____________ Name: _______________________________________ Atty. for: ______________________________________ Address: _______________________________________ City/State/Zip: __________________________________ Telephone: _____________________________________ ENTERED: Dated:________________________________, __________ ___________________________________________ Judge Judge's No. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS