Fillable Verbal Release Form printable pdf download

111 17

Ave East,

111 17

Ave East

610 30

Ave West

Suite 101

Alexandria, MN 56308

Phone: 320-762-1511

Phone: 320-763-5123

Phone: 320-762-1144

Fax: 320-762-6127

Fax: 320-763-7883

Fax: 320-762-1935

VERBAL RELEASE FORM

Patient Name: __________________________________________________________ Date of Birth: _____________________

Previous Name (if any): __________________________________________________ Phone Number: ____________________

Street Address: ________________________________________________________ Internal Use MRN#:_________________

City: _____________________________ State: __________ Zip Code: _______________ Last 4 Digits SSN: _____________

This will authorize these facilities to release information as designated below, to the following individuals for the purpose of assisting with my health care and/or

finances, unless otherwise noted:

Name: _________________________________

Relationship: _________________

Phone Number: _________________

All Medical Records* (Including Billing and Appointment)

Billing Information Only

Appointment Information Only

Name: _________________________________

Relationship: _________________

Phone Number: _________________

All Medical Records* (Including Billing and Appointment)

Billing Information Only

Appointment Information Only

Name: _________________________________

Relationship: _________________

Phone Number: _________________

All Medical Records* (Including Billing and Appointment)

Billing Information Only

Appointment Information Only

*All medical records for the previous 3 years including alcohol and/or drug abuse treatment records, psychiatric records

and/or records related to communicable diseases, including HIV, STD and/or pregnancy testing. This does not include

records from other facilities. If other than 3 years, indicate dates requested

 Special Disclosure: With the exception of Psychotherapy notes, all records pertaining to psychiatric/mental health, chemical

dependency and/or AIDS/HIV related illness/testing will be released unless otherwise indicated by initialing here:

_____________

 I understand I may revoke this authorization by written request at any time to the address listed at the top of this form. I

understand that the revocation will not apply to information that has already been released in response to this authorization.

 This authorization will automatically expire one year from the date of my signature, or ________________ (period of time, for

example, 2 days, 3 weeks or 5 months) from the date of my signature, if specified here. The expiration period noted here may

exceed one year only in certain situation as specified in Minnesota statute 144.335 3a: for release to a provider in connection

with current treatment: for release for purposes of payment claims, fraud investigation or quality of care.. As noted above, I

understand I may revoke this authorization by written request at any time to the address listed above.

 I understand that once information is released pursuant to this authorization, these facilities cannot prevent the re-disclosure of

the information to another third party.

 I understand this authorization must be filled out completely, signed and dated in order to be considered valid. A fax or

photocopy that has not been altered will be considered as valid as an original.

 These facilities will not condition treatment on my signing this authorization.

 Alexandria Clinic, a service of Douglas County Hospital, and Douglas County Hospital share an electronic medical record with

CentraCare Health System: Allergy, Asthma and Pulmonary Assoc; Williams Integracare Clinic; Tri County Health Care; Big Lake

Clinic; Douglas County Hospital; Rice Memorial Hospital; Central MN Neurosciences; New River Medical Center: Authorizing the

release of the following items: Medication List, Allergy List, Problem List, Immunization Data and/or Medical History includes the

release of this information from all sites that share an electronic medical record.

___________________________________

_____________________________________

___________________

Authorized Person’s Authority to Sign

Signature of Patient/Authorized Person

Date

(Parent, Guardian, Health Care Agent, Etc)

Copy For Patient:

Patient Declined Copy:

ID Checked:

Verbal Release Form

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