Minnesota Standard Consent Form To Release Health Information Page 2
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3Minnesota Standard Consent Form to Release Health Information
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1
Patient information
First name _______________________ Middle name _______________________ Last name ____________________
Patient date of birth ___ /___ / _______ Previous name(s) _________________________________________________
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Home address ___________________________________________________________________________________
City ______________________________________________State ____________ Zip code _____________________
Daytime phone _____________________________________E-mail address (optional)__________________________
Medical Record/patient ID number (optional) ____________________________________________________________
2
Contact for information about how this form was filled out (optional) :
I give permission for the organization(s) listed in section 3 permission to talk to
First name ________________________Last name ____________________________ about how this form was completed,
this person can be reached at: Daytime phone _________________ E-mail address (optional) ________________________
3
I am requesting health information be released from at least one of the following:
Organization(s) name _____________________________________________________________________________
Specific health care facility or location(s) _______________________________________________________________
Specific health care professional’s name(s) _____________________________________________________________
4
I am requesting that health information be sent to:
Organization(s) name _____________________________________________________________________________
And/or person: First name ___________________________ Last name _____________________________________
Mailing address _________________________________________________________________________________
City _____________________________________________ State ____________ Zip code ______________________
Phone (optional) ___________________________________ Fax (optional) __________________________________
Information needed by (date) ___ / ___ / _______ (optional)
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5
Information to be released
IMPoRtAnt: indicate only the information that you are authorizing to be released.
___ Specific dates/years of treatment _________________________________________________________________
___ All health information
(see description in instructions for what is included)
oR to only release specific portions of your health information, indicate the categories to be released:
___ History/Physical
___ Mental health
___ HIV/AIDS testing
___ Discharge summary
___ Radiology report
___ Laboratory report
___ Emergency room report
___ Progress notes
___ Radiology image(s)
___ Surgical report
___ Care plan
___ Photographs, video, digital or other images
___ Medications
___ Immunizations
___ Billing records
___ Other information or instructions _________________________________________________________________
the following information requires special consent by law. Even if you indicate all health information, you must
specifically request the following information in order for it to be released:
___ Chemical dependency program
(see definition in instructions)
___ Psychotherapy notes
(this consent cannot be combined with any other; see instructions)
This form was approved by the Commissioner of the Minnesota Department of Health on January 30, 2008.
JAn2008
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