Fillable Printable Hospital Release Sample Form

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

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