Fillable Minnesota Standard Consent Form To Release Health Information printable pdf download

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Instructions for Minnesota Standard Consent Form to Release Health Information

Important: Please read all instructions and information before completing and signing the form.

An incomplete form may not be accepted. Please follow the directions carefully. If you have any questions about the

release of your health information or this form, please contact the organization you will list in section 3.

This standard form was developed by the Minnesota Department of Health as required by the Minnesota Health Records Act of

2007. If completed properly, this form must be accepted by the health care organization(s), specific health care facility(ies), or

specific professional(s) identified in section 3.

A fee may be charged for the release of the health information.

The following are instructions for each section. Please type or print as clearly and completely as possible.

Important: There are certain types of health information

| Include your full and complete name. If you have a suffix

that require special consent by law.

after your last name (Sr., Jr., III), please provide it in the

“last name” blank with your last name. If you used a

Chemical dependency program information comes from

previous name(s), please include that information. If you

a program or provider that specifically assesses and treats

know your medical record or patient identification number,

alcohol or drug addictions and receives federal funding. This

please include that information. All these items are used to

type of health information is different from notes about a

identify your health information and to make certain that

conversation with your physician or therapist about alcohol

only your information is sent.

or drug use. To have this type of health information sent,

| If there are questions about how this form was filled out,

mark or initial on the line at the bottom of page 1.

this section gives the organization that will provide the

Psychotherapy notes are kept by your psychiatrist, psy-

health information permission to speak to the person listed

chologist or other mental health professional in a separate

in this section. Completing this section is optional.

filing system in their office and not with your other health

| In this section, state who is sending your health information.

information. For the release of psychotherapy notes,

you must complete a separate form noting only that

Please be as specific as possible. If you want to limit what

category. You must also name the professional who

is sent, you can name a specific facility, for example Main

will release the psychotherapy notes in section 3.

Street Clinic. Or name a specific professional, for example

chiropractor John Jones. Please use the specific lines. Providing

| Health information includes both written and oral information.

location information may help make your request more clear.

If you do not want to give permission for persons in section 3

Please print “All my health care providers” in this section

to talk with persons in section 4 about your health information,

if you want health information from all of your health care

you need to indicate that in this section.

providers to be released.

| Please indicate the reason for releasing the health information.

| Indicate where you would like the requested health

If you indicate marketing, please contact the organization

information sent. It is best to provide a complete mailing

in section 4 to determine if payment or compensation is

address as not everyone will fax health information. A place

involved. If payment or compensation to the organization

has been provided to indicate a deadline for providing the

is involved, indicate the amount.

health information. Providing a date is optional.

| This consent will expire one year from the date of your

| Indicate what health information you want sent. If you want

signature, unless you indicate an earlier date or event.

to limit the health information that is sent to a particular

Examples of an event are: “60 days after I leave the

date(s) or year(s), indicate that on the line provided.

hospital, ” or “once the health information is sent.”

For your protection, it is recommended that you initial instead

| Please sign and date this form. If you are a legally

of check the requested categories of health information.

authorized representative of the patient, please sign, date

This helps prevent others from changing your form.

and indicate your relationship to the patient. You may be

EXAMPLE: ____ All health information

asked to provide documents showing that you are the

patient or the patient’s legally authorized representative.

If you select all health information, this will include any

information about you related to mental health evaluation

and treatment, concerns about drug and/or alcohol use,

HIV/AIDS testing and treatment, sexually transmitted

diseases and genetic information.

This form was approved by the Commissioner of the Minnesota Department of Health on January 30, 2008.

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Minnesota Standard Consent Form To Release Health Information

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