PATIENT AUTHORIZATION FOR RELEASE OF INFORMATION
TO: RE: ___________________
DOB: ___________________
SSN: ___________________
This is your full and sufficient authorization, pursuant to Minn. Stat. §144.293, to release to _________________________________________, and their representatives or employees, all medical information (but not that which involves treatment for alcohol and drug abuse, sickle cell anemia, or mental problems) maintained while I was a patient at your facility on any date, with the following exceptions: NO CONVERSATIONS. This authorization includes any and all itemized billing statements for treatment at your facility.
This information is needed for the purpose of litigation. I DO NOT authorize re-disclosure of this information by the third party using this authorization, including adverse medical providers. However, I understand that if this information is disclosed to a third party, the information may be re-disclosed by that third-party and may no longer be protected by federal privacy regulations.
This authorization specifically includes records prepared prior to the date of this authorization and records prepared after the date of this authorization during the pendency of this proceeding (including claims and potential claims).I understand that this authorization is voluntary and that my health care and payment for my health care will not be affected if I do not sign this form.
I understand that I may revoke this consent in writing at any time, but that such revocation may adversely affect the course of the proceeding requiring these records. Upon fulfillment of the above stated purpose, this consent will automatically expire without my express revocation. In any event, this authorization shall automatically expire one year from the date of the authorization pursuant to Minn. Stat. §13.05. A photocopy or fax of this authorization will be treated in the same manner as the original.
CONVERSATIONS BY THE BEARER OF THIS AUTHORIZATION WITH PHYSICIANS ARE NOT AUTHORIZED BY THIS RELEASE.
Signature of Patient/Guardian Relationship to Patient (if applicable)
Date
