RELEASE OF INFORMATION – AUTHORIZATION FORM

Authorization to Release Health Information

Patient
Information: Name: __________________________________________ Maiden Name/Alias: ______________________

Date of Birth:___________________________ Social Sec #:_________________________

Phone: _____________________________ MR#__________________________

Health Information ฀ Hennepin County Medical Center (Hospital and Clinics)
Released FROM: ฀ Hennepin County Adult Detention Center
฀ Other:
Person/Organization:________________________________________________
Street Address: ____________________________________________________
City/State/Zip: _____________________________________________________
FAX: ______________________________ Phone: _________________________
Health Information
Released TO: Person/Organization:________________________________________________
Street Address: ____________________________________________________
City/State/Zip: _____________________________________________________
FAX: ______________________________ Phone: _________________________
Health Information Date of Service: ______________________ Type of Visit: ______________________________
to be Released: History and Physical  Photographs  Radiology Reports
 Laboratory Reports  Discharge Summary  Radiology Images (not able to fax images)
 Emergency Room Report  Progress/Clinic Notes  Dental Report/X-rays
 Surgery Report  Care Plan  Visits Report
 Medications  Immunizations  Cardiac/EKG Reports
 Other: ____________________________________________________________

All information regarding alcohol/ drug use or abuse, mental health and/or HIV or AIDS WILL
BE RELEASED unless you tell us not to by initialing below:
______ Do Not Release Alcohol/Drug Use or Abuse records
______ Do Not Release Mental Health records
______ Do Not Release HIV/AIDS records
Type of Release: ฀ Hard Copies (paper) ฀ Verbal Exchange (no copies)
฀ CD (requires PDF viewing capability) ฀ Review of Record (no copies)
Purpose of  Personal Attorney Continued Care - Appt Date: ______________________
Release:  Insurance  Disability/ Social Security  Other: __________________________
There may be a charge/fee for copies of records.
Delivery Method Mail Fax Pick up by patient/authorized designee (requires photo ID)
Authorization/ This authorization will terminate in one year unless otherwise specified: ____________________.
Revocation I understand that I may stop this release at any time by writing to the HCMC’s HIM department. Once the health
information has been released to another facility or provider, there is no way to cancel or stop the release. I understand
that when the health information is released the information could be re-disclosed by the third party that receives it and
may no longer be protected by federal or state privacy laws. I understand that HCMC will not condition treatment,
payment, enrollment or eligibility for benefits on whether I sign the consent form. I understand that I must sign this form
to release my health information.

X_______________________________________ X_____________________________
Signature (If signing for a minor patient, I hereby state that my Date
parental rights have not been revoked by a court of law.)

____________________________________
Relationship to patient (if not patient)
NOTE: An adult patient (18 years or older) must authorize the release of their own information unless patient is
incapacitated or deceased. Legal documentation of the right of access by the signing individual may be required.
A photocopy of this authorization is as valid as the original.
Staff Use Only
Info Released By: ____________ Date: ________ Form of ID: DL State ID Passport Other:________
Health Information Management – Release of Information, 701 Park Ave – S7, Minneapolis, MN 55415 Phone: 612-873-3179
 Instructions for Completing Authorization to Release Health Information

To protect our patient’s confidential medical information we must have a valid, complete and legible authorization to disclose their
health information.

1. Patient Information: Print the patient’s:

- Full, legal name - Date of Birth - Include maiden name or any alias names used
- Phone number - Social security number
2. Health Information Released FROM: Check only one of the boxes. If you select Hennepin County Medical
Center it will include clinics, emergency room and hospital records; unless otherwise noted in section #4. If
choosing “Other” please provide the organization’s name and address to obtain information from.
3. Health Information Released TO: Print the name of the person or organization that is to receive the
information, be sure to include the complete address, city and state and/or fax number.
4. Health Information to be Released: Indicate a date of service, type of visit (clinic, inpatient, radiology, etc.) or
specific report types as listed on the form. If you want to authorize the release of your entire medical record,
check the other box and write Any and All on the line.
All sensitive information; including alcohol and drug use/abuse records, mental health records and
HIV/AIDS records will automatically be released unless the individual items are initialed. Initial each
line indicating the specific sensitive information you DO NOT want us to release.
5. Type of release:
 Verbal Exchange – Check this box if you are allowing verbal discussions of your health and billing
information with parties listed.
 Review – check this box if you are allowing the review of your medical record by the party listed in #3
above.
 Hard Copies – check this box if you are allowing paper copies of your information to be given to the
party listed in #3. Be sure to indicate what information should be release in the Health Information to
be Released section. If only allowing release of records relating to specific illness/injury please list it on
the Other line.
 CD – check this box if you are looking to have your information sent to party listed in #3 on a CD.
Please remember that if you need these records faxed you cannot choose this option. Also note that
the recipient of the CD will need to have computer applications that allow them to view a PDF file.
6. Purpose of Release: Check appropriate box or write in if other purpose. If you have an upcoming
appointment that these records are needed for, please provide the appointment date.
7. Delivery Method: Please check the box to indicate how the records should be sent to the party in #3.
 Mail – if you check this box please make sure you have a complete address for the party in #3.
 Fax – check this box for continued care release only and be sure to include a fax number for the party
in #3.
 Pick up by patient/designee – check this box if you want to have the information picked up.
Whomever you would like to pick up the information will need to be listed as the party in #3. The
person picking up the information will need to have a valid photo identification card.
 There may be a charge for records.
8. Authorization/Revocation: This authorization will terminate one year from the date signed unless you specify
an earlier date. Any medical information after the date of signature will not be released. If you need to have
your information sent after the date signed on this form please ask the staff for help. The patient or legal
representative must sign and date the authorization in order for it to be valid. If a legal representative signs we
will need a copy of document showing legal representation.

If help is needed to complete this form, you may contact the HCMC HIM Release of Information staff at 612-873-3179
or stop by the department located on Blue 1 at the times listed below:

- Monday - Friday, 7:00 AM – 5:30 PM

- Closed Saturdays, Sundays and Major Holidays