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