Release Of Information Form
ADVERTISEMENT
1SOUTHDALE PEDIATRIC ASSOCIATES LTD.
PATIENT AUTHORIZATION FOR
RELEASE OF INFORMATION
PATIENT
Print Legal Name: ________________________________________Date of Birth:_______________
INFORMATION
Street Address: ____________________________________________________________________
City: ______________________________________________ State: _________ Zip: _____________
Parents/Guardian:__________________________________________________________________
□ Southdale Pediatric Associates
□ Other
Health
Information
Person/Organization:______________________________________________________________
Released FROM:
Address: _______________________________________________________
_______________________________________________________
Phone: ___________________________FAX:_________________________
□ Southdale Pediatric Associates
□ Other
Health
Information
Person/Organization:_______________________________________________________________
Released TO:
Address: ________________________________________________________
________________________________________________________
Phone: ____________________________FAX:________________________
□ Clinic Visit notes
INFORMATION
All records will be released including information on genetic diseases
□ Immunization records
REQUESTED
and HIV/AIDS unless checked here □ Please DO NOT RELEASE
□ Lab reports
INFORMATION REGARDING: _________________________________
□ Xray reports Dates:_____________________
□ Other:____________________________________________________________________________
Southdale Pediatrics will only release records generated at our facility, if you need records from
another facility you must request them from that facility.
□ Personal Copy
□ Moving
□ Referral to specialist
PURPOSE FOR
□ Insurance
□ Other________________________
RELEASE
□ Changing Providers
METHOD OF
□ Paper copies □ Mail or □ Pick up (
): _________________
must be 7-10 business days after date signed
DELIVERY
Picture ID is required when picking up records. Written permission is required if someone other than
parent/ legal guardian or patient is picking information up.
CHARGES FOR
Requests for copies of CURRENT MEDICAL RECORDS (PREVIOUS TWO YEARS) generated by Southdale
COPIES
Pediatric Associates, Ltd. for personal use or to be sent to another physician will be PROVIDED AT NO
CHARGE.
Copies of COMPLETE MEDICAL RECORDS will be provided at a rate consistent with Minnesota statute
144.292. If complete copies are requested, we will notify you regarding the total charge prior to
copying.
AUTHORIZATION/
This authorization will terminate in one year unless otherwise specified: ______________________.
I understand that I may stop this release at any time by writing to Southdale Pediatric Associates, Ltd. Once the
REVOCATION
health information has been released to another facility or provider, there is no way to cancel or stop the
release. I understand that when the health information is released 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
Southdale Pediatrics will not condition treatment, payment, enrollment or eligibility for benefits on whether I
sign the consent form. I understand that I must sign this form to release my health information.
X ________________________________________
X___________________________________
Signature
Date
(If signing for a minor patient, I hereby state that my
parental rights have not been revoked by a court of law.)
_____________________________________
Relationship to patient (if not patient)
NOTE:
An adult patient (18 years or older) must authorize
the release of their own information unless patient is
incapacitated or deceased. Legal documentation of the
right of access by the signing individual may be required.
*A photocopy of this authorization is as valid as the original
.
SDPA 19 10/13
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal