Fillable Minnesota Standard Consent Form To Release Health Information (Page 3 of 3) in pdf

Minnesota Standard Consent Form to Release Health Information

Patient’s name _______________________________________________________

PAGE 2 oF 2

Health information includes written and oral information

By indicating any of the categories in section 5, you are giving permission for written information to be released and for

a person in section 3 to talk to a person in section 4 about your health information.

If you do not want to give your permission for a person in section 3 to talk to a person in section 4 about your health

information, indicate that here (check mark or initials) ______

Reason(s) for releasing information

___ Patient’s request

___ Review patient’s current care

___ Treatment/continued care

___ Payment

___ Insurance application

___ Legal

___ Appeal denial of Social Security Disability income or benefits

___ Marketing purposes (payment or compensation involved?

YES, amount _________________________ )

___ Other (please explain) _________________________________________________________________________

I understand that by signing this form, I am requesting that the health information specified in Section 5 be sent to the third

party named in section 4 above.

I may stop this consent at any time by writing to the organization(s), facility(ies) and/or professional(s) named in section 3.

If the organization, facility or professional named in section 3 has already released health information based on my consent,

my request to stop will not work for that health information.

I understand that when the health information specified in section 5 is sent to the third party named in section 4 above, the

information could be re-disclosed by the third party that receives it and may no longer be protected by federal or state privacy laws.

I understand that if the organization named in section 4 is a health care provider they will not condition treatment, payment,

enrollment or eligibility for benefits on whether I sign the consent form.

If I choose not to sign this form and the organization named in section 4 is an insurance company, my failure to sign will not

impact my treatment; I may not be able to get new or different insurance; and/or I may not be able to get insurance payment

for my care.

this consent will end one year from the date the form is signed unless I indicate an earlier date or event here:

Date ___ / ___ / ______ Or specific event _______________________________________________________________

yyyy

Patient’s signature

________________________________________________________ Date ___ /___ /______

yyyy

or legally authorized representative’s signature ______________________________________ Date ___ /___ /______

yyyy

Representative’s relationship to patient (parent, guardian, etc.) ______________________________________________

Print Form

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

JAn2008

Minnesota Standard Consent Form To Release Health Information Page 3