OR DER FOR THE APP OINTMENT OF CONFIDENTIAL INTER MEDIARY 2374 (Rev. 07/05) UNITED STATES OF AMERICA STATE OF ILLINOIS COUNTY OF DU PAGE IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT In the Matter of the Petition of CASE NUM BER For the Appointment of Confidential Intermediary File Stamp Here PETITION FOR APPOINTM ENT OF CONFIDENTIAL INTERM EDIARY Petitioner, , petitions this Honorable Court for the appointment of a Confidential Intermediary pursuant to the Adoption Act at 750 ILCS 50/18.3a (as revised January 1, 2004), and in support of this petition states as follows: 1. That is an adoptee, having a date of birth of , and on the date of filing this Petition said adoptee is years of age. 2. was adopted by on or about in County, Illinois. 3. That the Petitioner seeks the appointment of a Confidential Intermediary for the purpose of: obtaining/exchanging medical information with one or more mutually consenting biological relatives, and/or obtaining identifying information about one or more mutually consenting biological relatives, and/or arranging contact with one or more mutually consenting biological relatives. 4. That the Petitioner is: an adopted person over the age of 21, or the adoptive parent or legal guardian on behalf of an adopted person under the age of 21, or a birth parent of an adopted person over 21 years of age, or an adult child of deceased, adopted or surrendered person, or an adult birth sibling of an adopted person whose birth parent is deceased, or an adult birth sibling of deceased birth parent. 3. The Petitioner seeks the following biological relative(s): any/all living birth relatives over the age of 21, birth son(s) or daughter(s) over the age of 21, birth mother, birth father, birth sibling over the age of 21, Other: CHR IS KACHIR OUBAS, CL ERK OF THE 18TH J UDICIAL CIRCUIT COURT WHEATON, ILL INOIS 60189-0707 >>>> 2OR DER FOR THE AP POINTME NT OF CONFIDENTIAL INTER ME DIAR Y 2374 (Rev. 07/05) 6. If the petitioner is an adult child of a deceased adopted or surrendered person, and adult birth sibling of a deceased adopted or surrendered person or an adult sibling of a deceased birth parent, disclosure is of greater benefit than nondisclosure because: 7. Except as provided in paragraph 8 of this Petition, the Petitioner understands that the appointed Confidential Intermediary shall not have access to: 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), Medical Records, Financial Records, Credit Records, Banking Records, Adoption Home Studies, Attorneys records, or other personal records. 8. Additionally, the Petitioner understands 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. If the Petitioner is an adult adopted person or the adoptive parent of a minor and if the Petitioner has signed a written authorization to disclose personal medical information, adoption agency disclosing information to a confidential intermediary shall disclose available medical information about the adopted person from birth through adoption. WHEREFORE, your Petitioner prays that this Court appoint a Confidential Intermediary pursuant to the Adoption Act at 750 ILCS 50/18.3a, and for such other relief as may be necessary. Respectfully submitted, Petitioner Date VERIFICATION BY CERTIFICATION Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and believe and as to such matters the undersigned certifies as aforesaid that he verily believes the same to be true. Petitioner Date Name: PRO SE DuPage Attorney Number: Attorney for: Address: City/State/Zip: Telephone: CHR IS KACHIR OUBAS, CL ERK OF THE 18TH J UDICIAL CIRCUIT COURT WHEATON, ILL INOIS 60189-0707