Patient Authorization for Release of Medical Information

Patient Authorization for Release of Medical Information

For patients who want St. Paul Corner Drug to be able to share their private health information (PHI) with other individuals
Patient Information
Patient name

First NameLast Name
Patient date of birth

MonthDayYear
Date
Release of Information
Description of the specific information to be used or disclosed (check all that apply):*

Medication therapyMedication drug costsAny and all pharmacy informationOther
Person or entity requesting the information and authorized to make the requested use or disclosure (person signing the form; usually the Patient, but could also be a parent/legal guardian or Power of Attorney)*

First NameLast Name
Requester's date of birth*

MonthDayYear
Date
Recipient of the information (e.g., spouse, adult child)*

First NameLast Name
Recipient's date of birth*

MonthDayYear
Date
Expiration
If you would like this authorization to expire on a certain date, please enter that date below. Otherwise, if left blank, this authorization will remain in effect indefinitely or until a request to terminate is received in writing from the Patient or a Patient Representative.
This authorization should remain in effect from the date this form is signed until:

MonthDayYear
Patient Attestation
By signing this form, I understand that:
- I may inspect or copy the protected health information (PHI) to be used or disclosed
- I may revoke this authorization in writing by contacting St. Paul Corner Drug at the address below, attention Privacy Officer
- Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer protected by HIPAA
- I may refuse to sign this authorization and that St. Paul Corner Drug will not condition treatment or payment on my providing this authorization (except to the extent that the authorization is for research-related treatment, in which case St. Paul Corner Drug may refuse to provide that research-related treatment)
St. Paul Corner Drug
240 Snelling Avenue South
Saint Paul, MN 55105

I hereby authorize St. Paul Corner Drug to use or disclose the specific information described above, only for the purposes and parties also described.
Signature of Patient (or Patient Representative)*

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Patient Representative (if signed by Patient Representative)

First NameLast Name
Relationship to Patient (if signed by Patient Representative)
Proof of Power of Attorney (if signed by Patient Representative & applicable)

If you are a Patient Representative completing and signing this form on behalf of a Patient for whom you hold Power of Attorney, please upload proof of Power of Attorney here
Cancelof
Should be Empty:

Patient Authorization for Release of Medical Information

Patient Information

Release of Information

Expiration

Patient Attestation