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Minnesota Standard Consent Form to Release Health Information
1. Patient information
Name
First
Middle
Last
Patient date of birth
MM slash DD slash YYYY
Previous name(s)
Home address
City
State
Zip code
Daytime phone
E-mail address (optional)
Medical Record/patient ID number (optional)
2. Contact for information about how this form was filled out (optional)
I give permission for the organization(s) listed in section 3 permission to talk to
First name
Last name
3. I am requesting health information be released from at least one of the following
Organization(s) name
Specific health care facility or location(s)
Specific health care professional’s name(s)
4. I am requesting that health information be sent to
Organization(s) name
And/or person:
First
Last
Mailing address
City
State
Zip code
Phone (optional)
Fax (optional)
Information needed by date (optional):
5. Information to be released
IMPORTANT: indicate only the information that you are authorizing to be released
Specific dates/years of treatment
All health information (see description in instructions for what is included OR to only release specific portions of your health information, indicate the categories to be released:
Other information or instructions
Type here
Choose the ff
History/Physical
Mental health
HIV/AIDS testing
Laboratory report
Discharge summary
Radiology report
Emergency room report
Progress notes
Radiology image(s)
Surgical report
Care plan
Photographs, video, digital or other images
Medications
Immunizations
Billing records
Type here
The following information requires special consent by law. Even if you indicate all health information, you must specifically request the following information in order for it to be released
Chemical dependency program (see definition in instructions
Psychotherapy notes (this consent cannot be combined with any other; see instructions)
Patient’s name
6. Health information includes written and oral information
By indicating any of the categories in section 5, you are giving permission for written information to be released and for a person in section 3 to talk to a person in section 4 about your health information.
If you do not want to give your permission for a person in section 3 to talk to a person in section 4 about your health information, indicate that here
(check mark or initials)
Type Initials here
7 Reason(s) for releasing information
releasing info
Patient’s request
Review patient’s current car
Treatment/continued car
Payment
Insurance application
Legal
Appeal denial of Social Security Disability income or benefit
Marketing purposes (payment or compensation involved)
Sale (payment or compensation to entity maintaining the information
Other (please explain)
Type here
8. Consent
I understand that by signing this form, I am requesting that the health information specified in Section 5 be sent to the third party named in section 4.
I may stop this consent at any time by writing to the organization(s), facility(ies) and/or professional(s) named in section 3.
If the organization, facility or professional named in section 3 has already released health information based on my consent, my request to stop will not work for that health information.
I understand that when the health information specified in section 5 is sent to the third party named in section 4, the information could be re-disclosed by the third party that receives it and may no longer be protected by federal or state privacy laws.
I understand that if the organization named in section 4 is a health care provider they will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign the consent form.
If I choose not to sign this form and the organization named in section 4 is an insurance company, my failure to sign will not impact my treatment; I may not be able to get new or different insurance; and/or I may not be able to get insurance payment for my care.
This consent will end one year from the date the form is signed unless I indicate an earlier date or event here
Date
MM slash DD slash YYYY
Or specific event
9. Signature
Patient’s signature
Date
MM slash DD slash YYYY
OR legally authorized representative’s signature
Date
MM slash DD slash YYYY
Representative’s relationship to patient (parent, guardian, etc.)
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of any individual or family member of the individual, except as specifically allowed by this law
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