Department of Corrections and Community Supervision

Department of Health Form 5032: Authorization for Release of Health Information Pertaining to Inmates

Purpose of the Form:

To enable family, friends, or others to obtain health information relating to inmates. Currently privacy laws protect the confidentiality of individual’s medical information. This prohibits correctional staff from disclosing an inmate’s medical information with family members, friends, or others without the written authorization of the inmate. However, a properly completed and signed Department of Health Form 5032 (DOH-5032) will provide family, friends or others the ability to obtain medical information about those incarcerated.

Information Provided By Signed Form:

A properly completed and signed DOH-5032 form will allow access to an inmate’s health records including Alcohol/Drug Treatment, Mental Health Information, and Confidential HIV/AIDS related Information.

* Release of Alcohol/Drug Treatment, Mental Health Treatment and confidential HIV/AIDS-related Information will only be done if the inmate/patient or authorized representative specifies
the information to be disclosed and places their initials on the appropriate line on form.

**Please note that Mental Health records are maintained by the Office of Mental Health and not DOCCS and cannot be released by DOCCS.

Information Needed to Fill Out a Form:
What to do with the form:

-Family Members Filling Out a Form on Behalf of Inmate-

-Inmates Filling Out a Form-

For other Languages: