Authorization For Release Of Medical Records - South Lake Minnetonka Police Department
Download a blank fillable Authorization For Release Of Medical Records - South Lake Minnetonka Police Department in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Authorization For Release Of Medical Records - South Lake Minnetonka Police Department with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1South Lake Minnetonka Police Department
24150 Smithtown Road
Shorewood, Minnesota 55331
Mike Meehan
Office
(952) 474-3261
Chief of Police
Fax Line (952) 474-4477
Clear All Fields
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
Birthdate:
RE:
(Patient’s Name)
Fax Number
Use Dropdown to Select Facility
I authorize
(Name of Facility)
Use Dropdown to Select Officer
to release to
South Lake Minnetonka Police Department - 24150 Smithtown Road, Shorewood, MN 55331
(Name of person/organization/e-mail and mailing address)
information from the medical record maintained while I was a patient at the above facility during:
(Dates of hospitalization)
and/or for the medical condition of
(Specify illness or injury)
The information to be disclosed is:
Discharge Summary
Lab Reports
Consultation
Pathology
Check All
History and Physical
Emergency Room Report
Operative Report
Medications
Uncheck All
X-ray Reports
Progress / Clinic Notes / Care Plans
Any other information relevant to the investigation
I do not authorize the release of the following records:
This information is needed for the purposes of
I understand that I may revoke this authorization at any time, and without an expressed revocation, it will expire after
one year from the date of signature. I understand that when the health information is released the information could
be re-disclosed by the third party that receives it and may no longer be protected by federal and state privacy laws. I
understand that this facility, will not condition treatment, payment, enrollment or eligibility or benefits on whether I
sign the consent form. I understand that I must sign this form to release my health information.
01-08-2018
Signature of patient, parent or guardian
Date
Fax Release to at
Serving South Lake Minnetonka Communities of Excelsior, Greenwood, Shorewood and Tonka Bay
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business