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AUTHORIZATION TO RELEASE ADD / ADHD HEALTHCARE INFORMATION

Patient Name:

Date of Birth: ____________ Tech ID: ______________

Previous Name:

(if applicable)

Patient Phone: _________________________________

For reason of continuing care,

Organization Name: ____________________________________________________

I request and authorize:

Phone: ___________________

Address:

___________________________________________________________

Fax:

___________________

City, State: _____________________________________

Zip: ________________

to release healthcare information of the patient named above to:

Name:

Minnesota State University, Mankato Student Health Services

Email: healthservices@mnsu.edu

Fax (507) 389-5787

Phone: (507) 389-6276

Address:

21 Carkoski Commons

City:

Mankato

State:

Zip Code:

56001

Attention Deficit Disorder / Attention Deficit Hyperactivity Disorder Diagnosis



INCLUDING TESTING

Information regarding this authorization:

I understand that each transfer of Medical Records requires a new release form signed by the patient. I understand that I may revoke

the authorization at any time and that I will be asked to sign a written statement specifically revoking this authorization. I further

understand that any action taken on this authorization prior to the rescinded date is legal and binding.

I understand that my information may not be protected from re-disclosure by the recipient of the information. If the recipient is not

covered by privacy laws, the recipient could re-disclose the information.

I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment,

payment for services, or my eligibility for benefits; however, if a service is requested by a non-treatment provider (e.g. insurance

company) for the sole purpose of creating health information (e.g. physical exam), service may be denied if authorization is not given. If

treatment is research-related, treatment may be denied if authorization is not given.

I further understand that I may request a copy of this signed authorization. A photocopy of this release is valid to the same extent as an

original. This form can be found at /forms.html.

_________________________________________________

____________________

(Signature of Patient or Legal Representative)

(Date)

OFFICE USE: Sent by

____

Date

Verified Name/DOB ____________

THIS AUTHORIZATION EXPIRES SIXTY DAYS AFTER IT IS SIGNED.

Minnesota State University, Mankato Student Health Services Providers

MaryPat Anderson, MD; Tammy Diehn, APRN, CNP; Jodi Egeland, APRN, CNP, PMHNP;

Randall Hurd, MD; Todd Kanzenbach, MD; Toya Schmidtke, APRN, CNP

11/15

Authorization To Release Add / Adhd Healthcare Information Form - Minnesota Student Health Services

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