Patient Authorization For Release Of Protected Health Information

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Lakeview
Stillwater
Lakeview Health
HOSPITAL
MEDICAL GROUP
Hospitals, Clinics, Specialists
927 Churchill Street W. Stillwater, MN 55082
1500 Curve Crest Blvd. Stillwater, MN 55082
Phone: 651-430-4596 • Fax: 651-430-4660
Phone: 651- 439-1234 • Fax: 651-439-1547
Toll Free: 800-423-7212
Toll Free: 800-877-1588
PATIENT AUTHORIZATION FOR RELEASE OF PROTECTED INFORMATION
______________________________________________
____________________________
__________________________________
Patient Name
Previous Name (s)
Birth date
_________________________________________________________
______________________________________________________
Street Address
City
State
Zip
________________________________
__________________________________
_________________________________________
Phone Number (Home)
(Cell)
(Work)
INFORMATION RELEASED FROM
INFORMATION RELEASED TO/EXCHANGED WITH
 Lakeview Hospital
 Stillwater Medical Group
____________________________________________________________
 Other: _______________________________________
NAME (hospital, clinic, attorney, insurance company, individual )
_______________________________________
_____________________________________________
Street Address
Street Address
_______________________________________________
______________________________________________________
City
State
Zip
City
State
Zip
The Information to be disclosed is:
____ Complete Record
____ X-ray Report
____ Itemizations of Charges
____ ECG Report
____ Discharge Summary
____ History and Physical
____ Copies of X-ray Films/CD
____ Rehab (PT/OT/RT)
____ Consultation Report
____ Operative Report
____ ED Record
____ Immunizations
____ Pathology Report
____ Lab Report
____ Clinic Notes
____ Other (Specify)_______________
Release Method:
View My Record
Fax (pt. care only)________________________
Paper
CD
Verbal
The information is needed for the following purpose (s):
____
Insurance
____
Legal/Attorney
____
Personal
____
____
____
______________________________________________
Disability
Continuity of Care
Other (please explain)
Specific Dates/Years of Treatment_________________________________
MRN/ Chart #______________________________________________
Statement of Authorization:
I understand this authorization will be valid for 12 months from the date of my signature, unless a date, event or condition is
otherwise specified: _________________________
I understand that I may revoke this authorization in writing at any time by notifying the healthcare facility listed above.
Revoking this authorization does not apply to information that has already been released under this authorization.
I have the right to inspect or obtain a copy of the health information to be disclosed.
If the disclosed information goes to a healthcare provider or a health plan covered by federal privacy laws, it will be protected by
federal laws. Information that goes to other persons/entities may not be protected by state or federal privacy laws any may be
redisclosed.
I do not have to sign this form, treatment will still be provided to me if I do not sign this form. Payment for services is not
contingent upon me signing this form, unless those services are for the sole purpose of creating personal information for a third
party, such as a life insurance company.
I have the right to inspect and receive a copy of the material to be disclosed.
All records pertaining to psychiatric/mental health and /or HIV/HIV related illnesses will be released unless indicated here:
____ Do not release records related to mental health and/or HIV.
For Staff only: ID Verified by:________________Date:______________ Records were mailed, faxed, picked up on:__________________
____________________ ___________________________________________________________
_______________________________
Date
Signature of Patient/Legally Authorized Representative
Relationship to Patient
_____________________________________________________
___________________________________________________________
Reason Patient unable to sign
Signature of Witness
NOTE: A FEE MAY BE CHARGED IN ACCORDANCE WITH MN STATUTE 144.292 AND FEDERAL RULE 164.524
200 - 03 - rev 11/13

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