Form Mr 8185-C - Hospital Records Release Form printable pdf download

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:

Location

:______________________________Attn:_____________________ Fax #________________

*Faxing for patient care needs only



I Hereby Authorize HealthEast

to RELEASE information TO

(Select from above)

Name___________________________________________ Phone #___________________________________________

Address___________________________________________________________________________________________

Regarding the Following Patient:

Patient Name___________________________________________ Phone #_________________________________

Other Names___________________________________________ Date of Birth______________________________

Address____________________________________________________

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

Date

________________________________________________

_________________________________________

Relationship to Patient

Reason Patient Unable to Sign

_______________________________________________

_________________________________________

Signature of Witness (Verbal Authorization Only)

--------------------------------------------------------------For HealthEast Use Only--------------------------------------------------------

: ________________ Date: __________ MR

_______________

Medical Records Released By

 Copies

 Review

MR 8185-C 7/13

AUTHORIZATION FOR RELEASE OF INFORMATION

Doc Type = Release of Information

Original: Medical Record

Copy: Patient

Form Mr 8185-C - Hospital Records Release Form

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