Authorization For Disclosure Of Health Information Form - Minnesota Student Health Services

Minnesota State University Mankato – Student Health Services

21 Carkoski Commons, Mankato, MN 56001 • Email: healthservices@mnsu.edu • Phone: 507-389-6276 • Fax: 507-389-5787

Authorization for Disclosure of Health Information

PLEASE PRINT

Patient Name: __________________________________________ Date of Birth: _______________ Tech ID#: _________________

I hereby authorize:

❒ Disclose to ❒ Obtain from ❒ Exchange with

_________________________________________________

Student Health Services

Facility / Organization

Minnesota State University, Mankato

21 Carkoski Commons

_________________________________________________

Address

Mankato, MN 56001

Fax: 507-389-5787

_________________________________________________

City / State / Zip Code

(_____)_____________________(_____)________________

Phone Number

Fax Number

PURPOSE OF DISCLOSURE:

I specifically authorize the release of information relating to:

❒ Transfer to another clinic

❒ Psychological Health

❒ Continued Care

❒ Substance abuse (including alcohol/chemical use)

❒ Personal Use

❒ Sexually transmitted infections

❒ Other ________________________________________ ❒ HIV related information (Aids related testing)

___________________________________________________

___________________

Signature of Patient or Legal Representative

Date

SPECIFIC INFORMATION TO BE RELEASED:

❒ Any and all Medical Records

❒ Laboratory Reports

❒ Progress/Provider Notes

❒ Allergy Records

❒ X-ray Reports

❒ Injections/Medications

❒ Records regarding treatment for _______________________________________________________________________________

(Specific Condition or Injury)

❒ Specific Date Range:: From _____ / _____ / _____ to _____ / _____ / _____

Release Via: ❒ Patient Pickup ❒ Mail ❒ Fax

Information regarding this authorization:

I understand that each transfer of Medical Records requires a new release form signed by the patient, except the exchange of Counseling/Mental Health Records,

wherein the authorization is valid for one year. I understand that I may revoke the authorization at any time and that I will be asked to sign a written statement specif-

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 I further understand that any action taken on this authorization prior to the rescinded date is legal and binding.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

_____________________________________________________

____________________

( ______ ) __________________

(Signature of Patient or Legal Representative)

(Date)

(Telephone #)

Office Use Only

Sent by _______________ Date _______________

Note to health care providers: This document complies with the requirements of the Health Insurance Portability and accountability Act of 1996; the Minnesota

Government Data Practices Act; and the Minnesota Health Records Act regarding authorization to disclose protected health information. (See 45 CFR 164.508 c)

(1) (2002); Minn Stat.Sects 13.05, Subd. 4(d); and 144.335, Subd.3a (2002)

A member of the Minnesota State Colleges and Universities System and an Affirmative Action/Equal Opportunity University.

This document is available in alternative format to individuals with disabilities by calling Student Health Services at 507-389-6276 (V), 711 or 800-627-3529 (MRS/TTY). HTSE73FR_6/16