Authorization to Release Health Information

Authorization to Release Health Information

Complete this form to authorize the release of your protected information in accordance with HIPAA regulations. If you have questions, please contact the Records Department (records@relatemn.org).
Relate Counseling Center

5125 County Road 101, Minnetonka MN 55345

7700 Equitable Drive, Eden Prairie MN 55344

Phone: 952-932-7277

Fax: 952-932-9827
Client Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relate Counseling CenterOther
Organization/Individual's Name:*
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid fax number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relate Counseling CenterOther
Organization/Individual's Name:*
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid fax number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Release Information
Release RecordsVerbal/Written Communication (do not send Records at this time)Other
Mental Health RecordProgress NotesChemical Health NotesAppointment List onlyOther
All datesSpecific dates/treatment periods
List specific dates or treatment periods:
Coordination of Current CareTransfer of ServicesClient/Parent RequestCourt/Legal ProceedingsInsuranceOther
Expiration Date or Event (if left blank, authorization expires one year from today)
Additional Information:
I give permission for a member of Relate Counseling Center to talk to another individual about this form:
Please list the contact information for the individual:
Name, Phone, Email address
Health information includes written and oral information. If you do NOT want to give your permission for Relate Counseling Center to talk with the individual/organization listed above, please select "No" below.
HIPAA Authorization Statements
Right to Revoke: I understand that I may revoke this authorization at any time by providing written notice to RELATE INC., except to the extent that action has already been taken in reliance on this authorization.

Re-disclosure Risks: I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA privacy regulations.

Conditioning of Care: I understand that my treatment, payment, enrollment, or eligibility for benefits is not conditioned on my signing this authorization, except when permitted by law.
Acknowledgment of Understanding: By signing below, I acknowledge that I have read and understand this authorization.
Signature of Patient or Authorized Representative*
Name of Client or Authorized Representative:*

First NameLast Name
If signed by Authorized Representative, state relationship to client
Date Signed*

MonthDayYear
Date
Should be Empty:

Authorization to Release Health Information

Client Information

Release Information

Additional Information: