NorthStar Regional Medical Records Request

Medical Records Request Form

Chaska | Shakopee | Eden Prairie | Otsego
HIPAA Compliance

All medical records requests must be made via HIPAA secure form. Requests must have all information below accurate and complete. Complete records requests will be fulfilled within 10 business days.
Instructions: Please ensure ALL information on this form is complete or we cannot process this request.
Full legal name of party requesting records:

First NameLast Name
Client Legal Name:

First and Middle NameLast Name
Client Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Date of Birth:

MonthDayYear
Client Phone Number:
Please enter a valid phone number. No mobile opt-in or text message consent will be shared with third parties or affiliates.Format: (000) 000-0000.
Confidential Information Requested
I, First & Last Name authorize NorthStar Regional to:
Select one:

Disclose Confidential Information:Obtain Confidential Information:Exchange Confidential information with:
Who and how would you like to share information with:
Method for records to be sent:

FaxMailEmail. Email option is NOT a secure method. Please consider mail or fax. By selecting email, you are consenting to an unsecured method for records to be sent.
Name:
First Last
Mailling Address:
123 Home Street, City, State, ZIP
Phone Number:
Please enter a valid phone number. No mobile opt-in or text message consent will be shared with third parties or affiliates.
FAX Number (if required):
(000) 000-0000
Email:
example@example.com
The purpose for which this information may be disclosed:
Choose the information you would like disclosed:

TreatmentPatient AccessInsuranceSocial Security AppealCare CoordinationLitigationOther
Other: (Specify)
What information may be disclosed:
Select what you would like shared:

Diagnostic AssessmentBilling InformationAppointment InformationTreatment PlanDischarge SummaryVerbal Consultation-ExchangeAll Progress NotesOnly Last 3 Progress NotesPsychological Testing ResultsOther
Psychological Testing Results: (Specify)
Other: (Specify)
I agree that my HIV status and/or drug/alcohol usage may be disclosed.
(Initial Here) initials
Record Request Dates:
Starting Date:

MonthDayYear
Start Date
Ending Date:

MonthDayYear
End Date
This authorization expires (ends) 12-Months from the date the client authorizes request.
I understand that I may revoke this authorization at any time by notifying, in writing, the facility listed above. Revoking this authorization does not apply to information that has already been released under this authorization. I have the right to inspect or copy the health information to be disclosed. Information that goes to a health care provider or health plan covered by federal privacy laws will be protected by federal privacy laws. NorthStar Regional cannot re-disclose any information from other persons or entities as protected by state or federal privacy laws. I do not have to sign this form. Treatment will still be provided to me if I do not sign this form. Payment for services is not contingent upon me signing this form, unless those services are for the sole purpose of creating personal information for a third party, such as insurance companies. A fee may be charged for retrieval and copying of records according to MN 144.335 and Federal Rule 164.521.
Do you have additional information to share?
Provide additional information if needed:
Signature Authorizations:
Patient Signature:
Date:

MonthDayYear
Parent, Guardian, Personal Representative (if required):
Date:

MonthDayYear
Witness (if client is unable to sign):
Date:

MonthDayYear
Should be Empty:

Medical Records Request Form

HIPAA Compliance

Confidential Information Requested

Who and how would you like to share information with:

The purpose for which this information may be disclosed:

What information may be disclosed:

Record Request Dates:

This authorization expires (ends) 12-Months from the date the client authorizes request.

Do you have additional information to share?

Signature Authorizations: