Hospital Release Sample Form

MR 8185-C 7/13 AUTHORIZATION FOR RELEASE OF INFORMATION
Doc Type = Release of Information Original: Medical Record Copy: Patient
I Hereby Authorize HealthEast
Bethesda Hospital St John’s Hospital St. Joseph’s Hospital Woodwinds Health Campus
559 Capital Blvd St. Paul, MN 55103 1575 Beam Ave Maplewood, MN 55109 45 West 10
th
St. St. Paul, MN 55102 1925 Woodwinds Dr. Woodbury, MN 55125
Midway Surgery Center Midway Pain Center HealthEast Medical Imaging Other _____________________________
1700 University Ave St Paul, MN 55104 1700 University Ave St Paul, MN 55104 3640 Talmage Circle Ste. 100, Vadnais Heights MN 55434
Phone: 651-471-8000 Fax: 651-471-8080
TO REQUEST information FROM: _______________________________________________________________________
Facility name and address _______________________________________________________________________
I Hereby Authorize HealthEast to RELEASE information TO:
(Select from above)
Name___________________________________________ Phone #___________________________________________
Address___________________________________________________________________________________________
Regarding the Following Patient:
Patient Name___________________________________________ Phone #_________________________________
Other Names___________________________________________ Date of Birth______________________________
Address____________________________________________________
Records to be released: Date(s) treatment was received: ___________________________________________
Consultation Report Laboratory Report Radiology Other______________
Discharge Summary Operative Report Test Results
Emergency Room Report Pathology Report Photographs, Videos, Digital or Other Images
History and Physical Radiology Image Film
I authorize the release of information relating to: HIV/AIDS Testing/Treatment
Psychiatric Evaluation/Treatment Alcohol/Drug Abuse Evaluation/Treatment Genetic Testing/Evaluation
Purpose of Release:
Continuing/Transfer of Care Insurance Litigation Personal Use Other_________________
This authorization expires on the following date, event or condition: ______________________________.
If I do not specify any expiration date, event or condition, this authorization will expire in one year.
Statement of Authorization:
I understand that, except for research related treatment, HealthEast will not condition my treatment, payment, enrollment or eligibility for benefits
on my signing this authorization.
Except to the extent that action has already been taken, I understand that I may revoke this authorization at any time by giving written notification
to Health Information Management (Medical Records). A photocopy/fax of this authorization will be treated in the same manner as the original.
I do not authorize further release to any third party. I understand that once information is released as specified in this authorization, the facility,
their employees and my physician(s) cannot prevent the re-disclosure of that information. I hereby release each of them from any and all liability
arising directly or indirectly from disclosure authorized by this consent and any
re-disclosure of that information.
______________________________________________ ___________________
Signature of Patient/Legally Authorized Representative Date
________________________________________________ _________________________________________
Relationship to Patient Reason Patient Unable to Sign
_______________________________________________ _________________________________________
Signature of Witness (Verbal Authorization Only) Signature of Witness (Verbal Authorization Only)
--------------------------------------------------------------For HealthEast Use Only---------------------------------------- ----------------
Medical Records Released By: ________________ Date: __________ MR#_______________
Copies Review
Send requested information to:
Location:______________________________Attn:_____________________ Fax #________________
*Faxing for patient care needs only
HealthEast Hospitals Release of Information Services
University Park Medical Building Suite 180
1690 University Ave W
St Paul, MN 55104 Phone: 651-232-4999 Fax: 651-232-4887
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