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). (Para cambiar a español, selecciona el ícono de la bandera en la esquina superior derecha.)
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.
I am requesting health information be released from:
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
I am requesting health information be sent to:
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
Type(s) of Authorization

Other
Specific Information to be Released

Other
Date Range
List specific dates or treatment periods:
Purpose of Release

Other
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: