CFS 600-3: Release of Information

Please read the instructions below prior to completing the request. Failure to follow instructions may result in a processing delay. 

Instructions:
Please complete one request for each entity you would like to release information to. This form is not for the "exchange" of information; two separate form submissions are required to release information between agencies/persons.

Please be aware of the following when completing the request:
1. Do not use acronyms anywhere in the request.
2. Provider and receiver information cannot be generic, e.g. GAL, physician, and caseworker are not acceptable. Please provide the specific name and address of the of person/ agency.
3. Use the appropriate type of information category and do not repeat the same specification in another category.
4. When specifying the type of information being released, do not use non-specific language such as records, reports, and assessments. Never use "any and all".
5. Only use information type "other" when necessary.
6. Only request information absolutely necessary to release to each entity. For example, physicians, dentists, therapists, and schools likely need different information.
7. When completing the purpose for requesting this information, please keep in mind the minor, who is releasing the information, and who the information is being provided to.
8. Consent is never granted for redisclosure.

Form Submission

Requestor Information

First Name

Last Name

Please use an Illinois.gov email if possible. The completed consent will be returned to this email.

Phone Number

Please provide a direct phone number, and phone extension if applicable, where the requestor can be reached in case additional information is needed to process the request.

Phone Extension

***

Fax

Office of the Guardian - Consent Unit

Office of the Guardian - Consent Unit