Appendix II Sample Documents

• Library: Post-Conviction Practice: A Manual for Illinois Attorneys (2012 Ed.)

Appendix II: Sample Documents

Appendix II Sample Documents are available electronically at: http://www.isba.org/publications/postconviction Shaded fields are to be filled in with information regarding your case.

Appendix II.A: Release of Records By Prior Counsel

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize __________ /(facility) to release __________/(specific information to be released) From the records of __________

(number) (Name)

To:

___ Self ___ Authorized Attorney ___Healthcare Professional

___Other: __________

Name: __________

Address:__________

I hereby release and hold harmless,__________, and its employees, from any liability which may occur as a result of the disclosure and/or dissemination of the records or information contained therein resulting from the access permitted to the authorized attorney, healthcare facility, other agency as specified, and/or self. This consent is valid for 120 days from the date of the signature. I understand that I have a right to revoke this consent in writing at any time during the 120 day period.

Records disclosed may contain confidential medical information including mental health history and treatment, drunk and alcohol history, and acquired immune deficiency (AIDS) related records.

__________

Signature

__________

Date

__________

Witness

__________

Date

Appendix II.B: Release of Medical Records

AUTHORIZATION FOR RELEASE OF MEDICAL AND OTHER INFORMATION

I, (name)__________, hereby authorize

(facility) __________

to release: medical records (all information, records, documents, reports, clinical abstracts, histories, and charts of every kind and description, including any information related to HIV testing, AIDS and any AIDS-related syndromes, relating to my conduction, care, confinement, and treatment), psychiatric and psychological evaluations and records (including, but not limited to, alcohol and drug treatment records), authorization to speak with physicians, psychologists, psychiatrists, and/or other professionals.

From the records of __________

Number Name

To:

___ Self ___ Authorized Attorney

Name: __________

___ Healthcare Facility

Name:__________

___ Private Investigator Name:__________

___ Other: (specify)__________

Name:__________

Address: __________

I hereby release and hold harmless ENTER YOUR NAME AND WHOMEVER ELSE INCLUDING PRIVATE INVESTINGATORS OR MITIGATION SPECIALISTS from any liability which may occur as a result of the disclosure and/or dissemination of the records or information contained therein resulting from the access permitted to the authorized attorney, healthcare facility, other agency as specified, and/or self. This consent is valid for 120 days from the date of the signature. I understand that I have a right to revoke consent in writing at any time during the 120 day period.

Records disclosed may contain confidential medical information including mental health history and treatment, drug and alcohol history, and acquired immune deficiency (AIDS) related records.

__________

Signature

__________

Date

__________

Witness

__________

Date

Appendix II.C: Docket Sheet

STATE OF ILLINOIS APPELLATE COURT __________ DISTRICT

Docket Number __________

Case Title (Complete)

Appeal from __________ County

Circuit Court Number __________

Date of Notice of Appeal __________

Date of Judgment __________

Date of Post Trial Motion __________

Trial Judge __________

Felony ( )

Misdemeanor ( )

In Custody ( )

Out on Bond ( )

DOCKETING STATEMENT (Criminal)

Counsel On Appeal

For Appellant (s)

Name:__________

Address: __________

Telephone:__________

Trial Counsel, If Different

Name: __________

Address: __________

Telephone:__________

Counsel on Appeal

For Appellee (s)

Name: __________

Address: __________

Telephone:__________

Court reporting personnel

(If more space is needed, use other side.)

Name: __________

Address: __________

Telephone:__________

Appendix II.C:...