Fillable Printable Health Consent Form - Minnesota
Fillable Printable Health Consent Form - Minnesota
Health Consent Form - Minnesota
JULY2014
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 might 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,
Minnesota Statutes, section 144.292, subdivision 8. The form must be accepted by a Minnesota provider as a legally enforceable request
under the Minnesota Health Records Act. 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.
1
Include your full and complete name. If you have a suffix after
your last name (Sr., Jr., III), please provide it in the “last name”
blank with your last name. If you used a previous name(s), please
include that information. If you know your medical record or
patient identification number, please include that information.
All these items are used to identify your health information and
to make certain that only your information is sent.
2
If there are questions about how this form was filled out, this section
gives the organization that will provide the health information
permission to speak to the person listed in this section.
Completing this section is optional.
3
In this section, state who is sending your health information.
Please be as specific as possible. If you want to limit what
is sent, you can name a specific facility, for example Main Street
Clinic. Or name a specific professional, for example chiropractor
John Jones. Please use the specific lines. Providing location
information may help make your request more clear. Please print
“All my health care providers” in this section if you want health
information from all of your health care providers to be released.
4
Indicate where you would like the requested health information
sent. It is best to provide a complete mailing address as not
everyone will fax health information. A place has been provided
to indicate a deadline for providing the health information.
Providing a date is optional.
5
Indicate what health information you want sent. If you want to
limit the health information that is sent to a particular date(s)
or year(s), indicate that on the line provided.
For your protection, it is recommended that you initial instead
of check the requested categories of health information.
This helps prevent others from changing your form.
EXAMPLE: All health information
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.
Important: There are certain types of health information that
require special consent by law.
Chemical dependency program information comes from a
program or provider that specifically assesses and treats alcohol
or drug addictions and receives federal funding. This type of
health information is different from notes about a conversation
with your physician or therapist about alcohol or drug use. To
have this type of health information sent, mark or initial on the
line at the bottom of page 1.
Psychotherapy notes are kept by your psychiatrist, psychologist
or other mental health professional in a separate filing system
in their office and not with your other health information. For
the release of psychotherapy notes, you must complete
a separate form noting only that category. You must also
name the professional who will release the psychotherapy
notes in section 3.
6
Health information includes both written and oral information. If you
do not want to give permission for persons in section 3 to talk with
persons in section 4 about your health information, you need to
indicate that in this section.
7
Please indicate the reason for releasing the health information. If
you indicate marketing, please contact the organization in section 4
to determine if payment or compensation is involved. If payment or
compensation to the organization is involved, indicate the amount.
8
This consent will expire one year from the date of your signature,
unless you indicate a different date or event. Examples of an
event are: “60 days after I leave the hospital,” or “once the health
information is sent.”
9
Please sign and date this form. If you are a legally authorized
representative of the patient, please sign, date and indicate
your relationship to the patient. You may be asked to provide
documents showing that you are the patient or the patient’s
legally authorized representative.
This form was approved by the Commissioner of the Minnesota Department of Health
on January 30, 2008 and updated in July 2014.
First name _______________________ Middle name ________________________ Last name ______________________
________ Previous name(s) ___________________________________________________
Home address ____________________________________________________________________________________
City ______________________________________________State ____________ Zip code _______________________
Daytime phone ______________________________________E-mail address (optional) ____________________________
Medical Record/patient ID number (optional) __________________________________
First name ________________________Last name ______________________________
Daytime phone ___________________ E-mail address (optional) __________________________
Organization(s) name ________________________________________________________________________________
Specific health care facility or location(s) __________________________________________________________________
Specific health care professional’s name(s) ________________________________________________________________
Organization(s) name _______________________________________________________________________________
First name ____________________________ Last name ______________________________________
Mailing address ___________________________________________________________________________________
City _____________________________________________ State ____________ Zip code _______________________
Phone (optional) ____________________________________ Fax (optional) ____________________________________
___ / ___ / _______ (optional)
Specific dates/years of treatment ____________________________________________________________________
All health information
(see description in instructions for what is included)
History/Physical
Laboratory report
Emergency room report
Surgical report
Medications
Other information or instructions _____________________________________________________________________
Chemical dependency program
(see definition in instructions)
Psychotherapy notes
(this consent cannot be combined with any other; see instructions)
MM DD YYYY
MM DD YYYY
HIV/AIDS testing
Radiology report
Radiology image(s)
Photographs, video, digital or other images
Billing records
Mental health
Discharge summary
Progress notes
Care plan
Immunizations
This form was approved by the Commissioner of the Minnesota Department of Health on January 30, 2008 and updated in July 2014.
JULY2014
PAGE 1 OF 2
Minnesota Standard Consent Form to Release Health Information
Patient date of birth
1
Patient information
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
about how this form was completed,
this person can be reached at:
3
I am requesting health information be released from at least one of the following:
4
I am requesting that health information be sent to:
And/or person:
Information needed by (da
te)
5
Information to be released
IMPORTANT: indicate only the information that you are authorizing to be released.
OR to only release specific portions of your health information, indicate the categories to be released:
___ /___ /
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:
___ /___ /______
___ /___ /______
6
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) ______
7
Reason(s) for releasing information
8
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.
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, 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
9
Patient’s signature Date
OR legally authorized representative’s signature Date
Minnesota Standard Consent Form to Release Health Information
Patient’s name _____________________________________________________________________ PAGE 2 OF 2
MM DD YYYY
MM DD YYYY
MM DD YYYY
PRINT FORM
This form was approved by the Commissioner of the Minnesota Department of Health on January 30, 2008 and updated in July 2014.
JULY2014
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? NO YES, amount____________ )
Sale (payment or compensation to entity maintaining the information? NO YES)
Other (please explain) ____________________________________________________________________________
___ / ___ / ______ Or specific event ________________________________________________________________
______________________________________________________
__________________________________________
Representative’s relationship to patient (parent, guardian, etc.) __________________________________________________
