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BHIP Template Consent Toolkit for ILHIE Direct 

The Behavioral Health Integration Project (BHIP) Template Consent Toolkit is designed to provide an easy, streamlined process for behavioral health providers to obtain and manage patient consent, specifically as it relates to exchanging patient information through ILHIE Direct, point-to-point secure messaging. This template consent tool-kit for ILHIE Direct offers forms that can be adapted to the operating standards of providers in exchanging health information with healthcare partners.

The Toolkit consists of three main elements: A sample consent form, a notices of privacy practices (NPP) insert, and a table comparing the consent guidelines of the Health Insurance Portability and Accountability Act (HIPAA), Public Health Code 42 CFR, and Illinois state mental health confidentiality law. Also included are some instructional materials to give you further guidance on using the Toolkit and managing consent.

Please note that neither the sample consent form or the NPP are required for use, but rather are suggested tools available for your use. Please see below for additional information and links to download the BHIP Toolkit documents.

Download The Full BHIP Toolkit (zip file) - Or click the links below for the individual Toolkit documents.
  1. Notice of Privacy Practices (NPP) Insert

This template consent tool kit was prepared with funds under grant number 1UR1SMO60319-01, -02 and supplemental grant number 3UR1SM060319-02S1 from SAMHSA/HRSA, U.S. Department of Health and Human Services.  The statements, findings, conclusions and recommendation are those of the author(s) and do not necessarily reflect the view of SAMHSA/HRSA or the U.S. Department of Health and Human Services.


Consent Form Instructions

About ILHIE Direct (visit

The Illinois Office of Health Information Technology is pleased to present you with the enclosed Illinois Health Information Exchange (“ILHIE”) Direct Secure Messaging System Consent Form (the “Consent Form”). ILHIE has created a direct, secure, encrypted, electronic messaging service (called “ILHIE Direct”) that supports secure electronic communication between health care providers. ILHIE Direct is designed to help providers easily and securely share information such as referrals, patient summaries and lab results to enhance patient care. In doing so, ILHIE aims to improve continuity of care, support the “Meaningful Use” of electronic health records under the Medicare and Medicaid incentive programs, and advance the patient-centered medical home model of care.    

What is the ILHIE Direct Consent Form?

The Consent Form provides your patients with the opportunity to allow you to share their health information with other providers using ILHIE Direct. The Consent Form meets all requirements established by applicable Federal and State law, including the Federal Confidentiality of Alcohol and Drug Abuse Patient Records Regulations, 42 C.F.R. Part 2 (“Federal Regulations”), the Illinois Mental Health and Developmental Disabilities Confidentiality Act, 740 ILCS 110/5 (“IMHDDCA”), and the Health Insurance Portability and Accountability Act of 1996, 45 C.F.R. parts 160 and 164 (“HIPAA”). In addition to informing your patients of certain information as required by these laws, the Consent Form addresses these issues:

Why is the ILHIE Direct Consent Form Necessary?

According to the Federal Regulations, the IMHDDCA, and HIPAA, patients must consent in writing to the release of their protected health information in most circumstances. Use of your patients’ health information in ILHIE Direct is one of those circumstances. 

How to Properly Complete the ILHIE Direct Consent Form

Before you may share a patient’s health information using ILHIE Direct, you should explain the Consent Form to the patient. If the patient is a minor or has a personal representative, then you should explain the Consent Form to the patient’s parent/guardian or personal representative. Explain to the patient/personal representative the following, which traces the sections of the Consent Form:
  • WHO MAY DISCLOSE - Patients may list the name(s) of provider(s) they authorize to disclose their information.
  • WHAT MAY BE DISCLOSED - Disclosure of all of a patient’s health information is the default.  However, patients should understand that they may choose to limit disclosure to specific information only by writing in the limitation.
  • WHO MAY RECEIVE - Patients may list the name(s) of the provider(s) they authorize to receive their health information. Multiple parties can be listed on one Consent Form, and all parties needing the health information should be identified to avoid the legal prohibition on redisclosure.
  • PURPOSES - Patients may check any or all of the following boxes listing the purposes for which their health information may be disclosed: their treatment, coordination of their care among their providers, and improving the provider’s health care operations.
  • EXPIRATION - The Consent Form automatically expires after 1 year. However, patients may choose an earlier expiration date by filling in the desired date where indicated.
  • REVOCATION - Patients should understand that they may revoke their permission to disclose their health information at any time, but revocation will not impact disclosures previously made in reliance on the Consent Form.
  • INSPECTION - Patients should be informed of their right to inspect and copy their health information.
  • FEDERAL LAW - Patients should understand that special protections apply to certain kinds of health information. Specifically, they should understand that special protections are granted to substance abuse treatment information pursuant to the Federal Regulations and mental health and developmental disabilities information under the IMHDDCA.

Who May Sign the ILHIE Direct Consent Form?

Generally, only patients may give consent to use or disclose their health information. However, there are situations where a patient’s parent, guardian or personal representative is the one who must consent. The following chart sets forth those individuals who can serve as a personal representative for adults/emancipated minors for purposes of authorizing uses and disclosures of health information. Please note that if a guardian/personal representative signs the Consent Form, he/she must also indicate his/her authority to act on behalf of a patient. If a patient is a mental health patient, then a witness must also sign and date the Consent Form.








If Patient Is:


Then Person Who May Sign Is:




If Patient Is:


Then Person Who May Sign Is:


Adult Patient






Adult Patient




Emancipated Minor Patient






Emancipated Minor Patient




Incompetent Adult Patient/Emancipated Minor: Adjudicated Incompetent


Court-appointed guardianorPerson appointed under a Power of Attorney for Health Care




Adult Patient/Emancipated Minor Who Has Been Determined To Be Incompetent For Decisions Related To Treatment Other Than Mental Health


Agent under Power of Attorney for Health CareorIf no Power of Attorney, Health Care Surrogate


Incompetent Adult Patient/Emancipated Minor: Without Court Adjudication Of Incompetence


Program Director, but only for purposes of payment Use or disclosure of information for other purposes is not permitted without court order




Adult Patient/Emancipated Minor Who Has Been Determined To Be Incompetent For Decisions Related To ECT, Psychotropic Medication, Or Admission To Mental Health Facility


Attorney-in-fact under Mental Health Treatment Preference DeclarationorAgent under Power of Attorney for Health CareorHealth Care Surrogate


Deceased Persons


Executor, administrator, or other personal representativeorIf none, then patient’s spouseorIf none, then by any responsible member of the patient’s family




Finally, you must provide the patient with a copy of the signed and dated Consent Form and keep the original on file.