Sample Patient Information Form - Premier Sports And Spine Center

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Premier&Sports&and&Spine&Center
8577&Columbine&Rd
Eden&Prairie,&MN&55344
Phone:&952A479A0043
Fax:&952A944A1673
Print patient’s legal name ____________________________________________________ Birth date ___/___/___
Previous name _______________________________________________
(office use only: MR# ___________________ )
Phone numbers (Home) ____________________ (Work) _________________ (Other) ____________________
1. Please release my records from: (Who has your records?)
Clinic or organization (if not printed above): _____________________________________________________
Address: _____________________________________________ City: _______________________________
State: ______________ Zip code: ______________ Phone: __________________ Fax:__________________
2. Please release my records to: (Who needs your records?)
Person, clinic or organization (if not printed above): ________________________________________________
Address: _____________________________________________ City: _______________________________
State: ______________ Zip code: ______________ Phone: __________________ Fax:__________________
If releasing records to yourself, should the envelope be marked “Personal and Confidential”? ☐ Yes ☐ No
3. These are the records I would like to release: ☐ All pertinent records (except films or slides), or check all that apply below
☐ Discharge summary
☐ Pathology reports
☐
☐ Counselor’s discharge summary
☐ Lab reports
☐
☐ History and physical exam
☐ X-ray / Radiology reports
☐ Psychological tests
☐ Consultation reports
☐ Films / CDs
☐ Send to MD only: Pathology slides / blocks
☐ Outpatient clinic notes
☐ Operative reports
☐ Other: ___________________________
For condition or dates of treatment: ___________________ (If blank, we will release 1 year’s worth of most recent records.)
Date records are needed by: __________________________. Will records be picked up? ☐ Yes ☐ No
☐ Continued care by another provider
☐ Insurance claim
☐ Personal use
4. Purpose:
☐ Social Security disability
☐ Attorney review
☐ Other ________________
5. I understand the following:
clinic or organization named above. This includes details of treatment for mental health, chemical dependency, sickle
cell anemia, genetic conditions and AIDS/HIV.
If I don’t want these to be released, I will place a check mark here: _______. I do not want the following
records released: ________________________________________________________________________.
apply to records that have already been released.
records cannot prevent them from being shared with a third party. At that point, the records may no longer be
protected by state and federal privacy laws.
___________
__________________________________________ ________________________________________
Date/Time
Signature of patient or authorized person
Authorized person’s authority to sign (proof required)
Reason patient is unable to sign: ☐ Minor ☐ Deceased ☐ Other: ___________________________________
Fairview Health Services AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
ORIGINAL to Chart
PHOTOCOPY

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