Release Of Medical Information Authorization Form

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ESSENTIA HEALTH
AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
1.
Patient
NAME
________________________________________________________Office Use Only
MRN___________________________
Information
Date of Birth____________________________________________________Day phone___________________________________
2.
Health Care
Provider or Clinic
NAME/ORGANIZATION ___________________________________________________Phone______________________________
or Hospital who
has the
Address ________________________________________________________________Fax________________________________
information you
want released?
City ___________________________________________State_____________________Zip________________________________
3.
Where do you
want the
NAME/ORGANIZATION ___________________________________________________Attention ___________________________
information to be
sent?
Address ________________________________________________________________Phone_____________________________
City ___________________________________________State_____________________Zip_______________________________
Fax Number (USED FOR URGENT PATIENT CARE ONLY)_________________________________________________________
4.
Why is it
Continuing care
Workers’ Compensation*
School
Personal use*
needed?
Insurance application*
Insurance payment/claim*
Legal*
Other_____________________
5.
What are the
approximate
Service Dates Between __________________________ to___________________________
dates of
information you
Send All Routine Records
want released?
Notes, History and Physical, Discharge Summary, Emergency Room, Lab, Radiology, Procedures, Test Results and Consultations
What do you want
Or Send Other Records
released?
Discharge Summary
Diagnostic Test Results
Consultations
Radiology Reports
Choose Routine for
History and Physical Exams
Pathology Reports
Psychological Testing
Laboratory Reports
items a health care
provider typically
Operative/Procedure Reports
Progress/Provider Notes
HIV/Aids Testing
Emergency Reports
needs, or select
individual records.
Rehab Reports (PT/OT/SP)
Chemical Dependency/Substance Abuse Reports
Form Completion
Other (specify content and dates)_____________________________________________________________________________
Radiology Films/MRI
Billing Records
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
6.
When is it
Date the information is needed? _____/_____/______Or Date of the appointment? _____/_____/______
needed?
To check on the status of your copies, please email
or call 866-203-7454.
7.
How do you want
Release Method / Format requested:
the information?
For copies:
Paper or
CD/DVD or
Fax (for patient care only)
Pick up (Photo ID is required at pickup time)
Verbal (no copies)
For Films/MRI:
CD/DVD
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.
8.
Patient Signature and
Date are required to
___________________________________________
_____________________________________________________
release records. If an
Patient Signature
Signature of Authorized Person
Authorized Person is
Parent of Minor
Court-appointed guardian/conservator
signing you must
Include legal documentation
__________________________
include legal
_____________________
Date
documentation.
Date
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

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