AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
________________________________________________________Office Use Only
Date of Birth____________________________________________________Day phone___________________________________
Provider or Clinic
or Hospital who
Where do you
NAME/ORGANIZATION ___________________________________________________Attention ___________________________
information to be
Fax Number (USED FOR URGENT PATIENT CARE ONLY)_________________________________________________________
Why is it
What are the
Service Dates Between __________________________ to___________________________
Send All Routine Records
Notes, History and Physical, Discharge Summary, Emergency Room, Lab, Radiology, Procedures, Test Results and Consultations
What do you want
Or Send Other Records
Diagnostic Test Results
Choose Routine for
History and Physical Exams
items a health care
needs, or select
Rehab Reports (PT/OT/SP)
Chemical Dependency/Substance Abuse Reports
Other (specify content and dates)_____________________________________________________________________________
Pathology Slides (are sent directly to the facility listed in step 3)
All information regarding alcohol and/or drug abuse or behavioral health will be released unless you restrict by initialing:
Do not release alcohol and/or drug abuse information
_____ Do not release behavioral health information
When is it
Date the information is needed? _____/_____/______Or Date of the appointment? _____/_____/______
To check on the status of your copies, please email
or call 866-203-7454.
How do you want
Release Method / Format requested:
Fax (for patient care only)
Pick up (Photo ID is required at pickup time)
Verbal (no copies)
This authorization lasts for one year after the date you sign it unless you enter a different expiration date here:_____________________________________.
I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified except
to the extent action has already been taken in reliance on it.
I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by
Federal privacy regulations.
I understand this consent for release of alcohol and/or drug abuse information is subject to revocation at any time except to the extent that the program or
person which is to make the disclosure has already acted in reliance on it.
I understand that Essentia Health may not condition my treatment, payment, enrollment, or eligibility for benefits on my signing this authorization.
I understand, upon request, I will receive a copy of this form after I have signed it.
I understand that in compliance with MN Statute 144.293, WI Administrative Code HHS117, NDCC 23-12-14, Federal Rule 45 CFR 164.524; Charges may
apply in ID. I may be required to pay a fee for retrieval and photocopying of records and/or supervising inspection of medical records.*
I understand a photocopy or fax of this form is the same as the original.
Patient Signature and
Date are required to
release records. If an
Signature of Authorized Person
Authorized Person is
Parent of Minor
signing you must
Include legal documentation
MAIL TO: Essentia Health
Telephone Number: 866-203-7454
Item # 39275
PO Box 19058
Fax Number: 920-593-3114
AUTH.001 Orig: 4/03 Rev: 11/30/2015
Green Bay WI 54307