Form Mr 8185-C - Hospital Records Release Form


HealthEast Hospitals Release of Information Services
University Park Medical Building Suite 180
1690 University Ave W
St Paul, MN 55104
Phone: 651-232-4999 Fax: 651-232-4887
I Hereby Authorize HealthEast
 Bethesda Hospital
 St John’s Hospital
 St. Joseph’s Hospital
 Woodwinds Health Campus
559 Capital Blvd St. Paul, MN 55103
1575 Beam Ave Maplewood, MN 55109
45 West 10
St. St. Paul, MN 55102
1925 Woodwinds Dr. Woodbury, MN 55125
 Midway Surgery Center
 Midway Pain Center
 HealthEast Medical Imaging
 Other _____________________________
1700 University Ave St Paul, MN 55104 1700 University Ave St Paul, MN 55104
3640 Talmage Circle Ste. 100, Vadnais Heights MN 55434
Phone: 651-471-8000 Fax: 651-471-8080
TO REQUEST information FROM: _______________________________________________________________________
→ _______________________________________________________________________
Facility name and address
Send requested information to:
:______________________________Attn:_____________________ Fax #________________
*Faxing for patient care needs only
I Hereby Authorize HealthEast
to RELEASE information TO
(Select from above)
Name___________________________________________ Phone #___________________________________________
Regarding the Following Patient:
Patient Name___________________________________________ Phone #_________________________________
Other Names___________________________________________ Date of Birth______________________________
Records to be released:
Date(s) treatment was received: ___________________________________________
 Consultation Report
 Laboratory Report
 Radiology
 Other______________
 Discharge Summary
 Operative Report
 Test Results
 Emergency Room Report
 Pathology Report
 Photographs, Videos, Digital or Other Images
 History and Physical
 Radiology Image Film
 HIV/AIDS Testing/Treatment
I authorize the release of information relating to:
 Psychiatric Evaluation/Treatment
 Alcohol/Drug Abuse Evaluation/Treatment
 Genetic Testing/Evaluation
Purpose of Release:
 Continuing/Transfer of Care
 Insurance
 Litigation
 Personal Use  Other_________________
This authorization expires on the following date, event or condition
: ______________________________.
If I do not specify any expiration date, event or condition, this authorization will expire in one year.
Statement of Authorization:
I understand that, except for research related treatment, HealthEast will not condition my treatment, payment, enrollment or eligibility for benefits
on my signing this authorization.
Except to the extent that action has already been taken, I understand that I may revoke this authorization at any time by giving written notification
to Health Information Management (Medical Records). A photocopy/fax of this authorization will be treated in the same manner as the original.
I do not authorize further release to any third party. I understand that once information is released as specified in this authorization, the facility,
their employees and my physician(s) cannot prevent the re-disclosure of that information. I hereby release each of them from any and all liability
arising directly or indirectly from disclosure authorized by this consent and any
re-disclosure of that information.
Signature of Patient/Legally Authorized Representative
Relationship to Patient
Reason Patient Unable to Sign
Signature of Witness (Verbal Authorization Only)
Signature of Witness (Verbal Authorization Only)
--------------------------------------------------------------For HealthEast Use Only--------------------------------------------------------
: ________________ Date: __________ MR
Medical Records Released By
 Copies
 Review
MR 8185-C 7/13
Doc Type = Release of Information
Original: Medical Record
Copy: Patient


00 votes

Related Articles

Related forms

Related Categories

Parent category: Business