PREMIER WOMENS HEALTH OF MINNESOTA

AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION
PREMIER WOMEN'S HEALTH OF MINNESOTA

This Release of Information is for MetroPartners ObGyn
Name*
Date of Birth*

MonthDayYear
Date
Previous Last Names*
If not applicable note N/A
Phone Number*
Address*
I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL'S PROTECTED HEALTH INFORMATION:
Person/Organization Name*
Address*
City*
State*
Zip Code*
Phone Number*
Please enter a valid phone number.
Reason for Disclosure (Choose only one option below)*

Treatment/Continuing Medical CareTransfer of CarePersonal UseInsuranceBilling or ClaimsLegal PurposesReferralSchoolEmploymentOther
WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?
Person/Organization Name*
Address*
City*
State*
Zipcode*
Phone Number*
Please enter a valid phone number.
WHAT INFORMATION CAN BE DISCLOSED?

Complete the following by indicating those items you want disclosed.
All medical records, excluding Radiology FilmsPrenatal RecordsRadiology reportsImmunization recordsOperative reportsLaboratory reportsHospital recordsVisit notesRecords about specific conditionOther
Records about specific condition: Please list condition below
Your initials are required to release the following information:
initials* Mental Health Records (excluding psychotherapy notes)
initials* Drug, Alcohol, or Substance Abuse Records
initials* Genetic Information (including Genetic Testing Results).
initials* HIV/AIDS Test Results/Treatment
DATES OF INFORMATION TO BE RELEASED:
All Clinic RecordsLast 6 MonthsLast 1 YearLast 2 YearsSpecific date of serviceOther
List the specific date of service for records below
FORMAT TO RECEIVE HEALTH INFORMATION:
Type a question*

MailElectronic PortalFaxPick up by PatientPick up by Other (Please fill out the next section)
If you would like your records pick up by somone other than yourself: Fill in the infomation below.

*ID will be required to pick up records*
Pickup by Other : please specify name
If Pickup by Other : please specify relationship to patient
Authorization Expiration Date:*

MonthDayYear
Date
Statement of Authorization
- I understand that I may revoke this authorization at any time with written notification to Medical Records, except to the extent that action has already been taken. A photocopy/fax/scanned image of this authorization will be treated in the same manner as an original.
- Premier Women's Health of Minnesota will not condition my treatment, payment, enrollment, or eligibility for benefits on my signing this authorization.
- 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*

Clear
Date*

MonthDayYear
Date
Please make sure your signature fills the box. Thank you.
Signature of ParentLegal Representative

Clear
Relationship to Patient
Date

MonthDayYear
Date
Should be Empty:

AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION

PREMIER WOMEN'S HEALTH OF MINNESOTA

I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL'S PROTECTED HEALTH INFORMATION:

WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?

WHAT INFORMATION CAN BE DISCLOSED?

Your initials are required to release the following information:

DATES OF INFORMATION TO BE RELEASED:

FORMAT TO RECEIVE HEALTH INFORMATION:

If you would like your records pick up by somone other than yourself: Fill in the infomation below.

*ID will be required to pick up records*

Statement of Authorization

ID will be required to pick up records