AUTHORIZATION FOR RELEASE OF INFORMATION

Individual Name: Tom Mamminga

Date of Birth: 06/23/1982

1. I authorize the use or disclosure of the above-named Individual’s protected health information as
described below.

2. The following individual or organization is authorized to make the disclosure:

Dr. Tibor Bocco, M.D., Neurological Surgery and Spine Surgery, 1 Westbrook Corporate Center,
Suite 800, Westchester, IL 60154

3. The type and amount of information to be used or disclosed is as follows:

All information regarding treatment received from Dr. Bocco from the period March 1, 2020 through
the date of this release.

4. I understand that the information in my health record may include information about behavioral or mental
health services and treatment for alcohol and drug abuse.

5. This information may be disclosed to and used by the following individual or organization:

Dr. Richard Cockarill, MD

Northwestern Medicine
446 E. Ontario, 7th Floor
Chicago, Illinois 60611
888-312-9495 (secure facsimile)

6. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this
authorization, I must do so in writing to Dr. Tibor Bocco. I understand that the revocation will not apply
to information that has already been released in response to this authorization. I understand that the
revocation will not apply to my Insurance company when the law provides my insurer with the right to
contest a claim under my policy. Unless otherwise revoked, this authorization will expire three months
from the date of signature.

7. I understand that authorizing the disclosure of this protected health information is voluntary. I can refuse
to sign this authorization. I understand that I may inspect or copy the information to be used or disclosed.
I understand that any disclosure of information carries with it the potential for an unauthorized re-
disclosure, and the information may not be protected by federal privacy regulations.

8. I understand that the District will provide me a copy of any fitness for duty reports prepared about me by
Dr. Cockerill.

__________________________________ ___________________________
Tom Mamminga Date

2886854.1
 AUTHORIZATION FOR RELEASE OF INFORMATION

Individual Name: Tom Mamminga

Date of Birth: 06/23/1982

1. I authorize the use or disclosure of the above-named Individual’s protected health information as
described below.

2. The following individual or organization is authorized to make the disclosure:

________________________________________________________________________

3. The type and amount of information to be used or disclosed is as follows:

All information regarding treatment received from the health care provider named in response to 2.
Above.

4. I understand that the information in my health record may include information about behavioral or mental
health services and treatment for alcohol and drug abuse.

5. This information may be disclosed to and used by the following individual or organization:

Dr. Richard Cockarill, MD

Northwestern Medicine
446 E. Ontario, 7th Floor
Chicago, Illinois 60611
888-312-9495 (secure facsimile)

6. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this
authorization, I must do so in writing to ____________(name of provider listed in 2 above). I understand
that the revocation will not apply to information that has already been released in response to this
authorization. I understand that the revocation will not apply to my Insurance company when the law
provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this
authorization will expire three months from the date of signature.

7. I understand that authorizing the disclosure of this protected health information is voluntary. I can refuse
to sign this authorization. I understand that I may inspect or copy the information to be used or disclosed.
I understand that any disclosure of information carries with it the potential for an unauthorized re-
disclosure, and the information may not be protected by federal privacy regulations.

8. I understand that the District will provide me a copy of any fitness for duty reports prepared about me by
Dr. Cockerill.

__________________________________ ___________________________
Tom Mamminga Date

2886854.1