release-and-disclose-patient-info

AALFA AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION

4465 White Bear Parkway White Bear Lake, MN 55110

P: 651.653.0062 F: 651.653.0288
Patient Information
Name
Date of Birth

MonthDayYear
Date
Address
Day Phone
City
State
Zip
Clinic/Health Care Provider Name:
Name
Fax Number
(Who has the information you want released?
Address
Day Phone
City
State
Zip
Receiving Party

(Where do you want the information sent? Who may have the information?
Name
Attention to
Address
Day Phone
City
State
Zip
Fax Number
Information to be Released

What do you want sent or released? Check the appropriate box.
Indicate Dates of Service

MonthDayYear
Date
Any and all clinic records (Includes all types of records listed below)
Release Instructions

How and When do you want the information?
ONLY Record Types Checked Below: Progress Notes Operative Reports Consultations Other (Please Specify):

History & Physical ExamProgress NotesOperative ReportsConsultationsRadiology ReportsPathology ReportsRehab Reports (PT/OT/ST)Chemical Dependency/ Substance Abuse RecordsMedication RecordsLaboratory RecordsOther
Date information is needed (please allow 48 hours): Date
Release Method/Format Requested:

PaperFaxVerbal
Fees may be charged in accordance with MN Statutes 144.292 and Federal Rule 45 C.F.R. 164.524
Purpose of Release

Why is it needed?
Transfer of Medical CareInsuranceMedical Treatment by SpecialistOther
This authorization lasts for one year after the date signed unless you enter a different date of expiration here:
Date

MonthDayYear
Date
- This authorization may be canceled at any time.
- AALFA health records may include records that we received from other organizations. If these records have been used by AALFA and filed in your AALFA record, these records may be released with your AALFA records.
- AALFA cannot prevent redisclosure of your information by the person or organization who receives your records under this authorization, and that information may not be covered by state and federal privacy protections after it is released. By signing this authorization, you release AALFA from any and all liability resulting from redisclosure by the recipient.
- Your signature indicates that you have read and understand this form, and authorize release of your information as described above.
Patient Legal Guardian
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Patient Information

Clinic/Health Care Provider Name:

Receiving Party

Information to be Released

Release Instructions

Purpose of Release