Section 500.APPENDIX E    Adoption Records

Section 500.ILLUSTRATION H    Information Exchange Authorization Form

Illinois Department of Public Health

STATE OF ILLINOIS ADOPTION REGISTRY

INFORMATION EXCHANGE AUTHORIZATION

                I, _________________________, state that I am the person who completed the Registration Identification; that I am the age of _____ years; that I hereby authorize the Department of Public Health to give the (circle as applicable) (birth mother) (birth father) (birth sibling) (adopted/surrendered person) (adoptive mother) (adoptive father) (legal guardian(s)) the following:

(please check the information authorized for exchange)

        1.     Only my name and last known address.

        2.     A copy of my Illinois Adoption Registry application as specified in the application.

        3.     A copy of the original birth certificate of the adopted person.

        4.     A copy of the completed medical questionnaire.

I am fully aware that I can only be supplied with any information about each circled person if that person has duly executed an Information Exchange Authorization for the information which authorization has not been revoked; that I can be contacted by writing to

(insert your own name, complete mailing address and telephone number

or this same information for another person to contact)

I, a Notary Public, in and for the said county, in the state aforesaid, do hereby certify that _______________ personally known to me to be the same person whose name is subscribed to the foregoing Information Exchange Authorization, appeared before me in person and acknowledged that he/she signed such authorization as his/her free and voluntary act and that the statements in such authorization are true.

(Source:  Amended at 24 Ill. Reg. 11882, effective July 26, 2000)