allina-health-authorization-to-release-and-disclose-patient

SR-10290 11/2019 allinahealth.org/medicalrecords

ALLINA HEALTH

AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION

Internal Use

Only

Completed By Initials : ___________ Date: ___________

PATIENT

INFORMATION

Patient name Date of Birth

Street Address Email Address

City State Zip Code Phone Number

RELEASE MY

MEDICAL

RECORDS FROM

**check one option

Allina Health (optional: specify location or provider below):

Hospital/Clinic/Provider (required: specify name below)

Street Address Phone Number

City State Zip Code Fax Number

SEND MY MEDICAL

RECORDS TO

**address field is

required

Person/Business/Hospital/Clinic Phone Number Fax Number

Street Address City State Zip Code

PURPOSE FOR

RELEASE

Continuing Care Personal Use/Review * Litigation/Legal * Insurance Application * Insurance Payment/Claim

Social Security Disability * Social Security Appeal Disability Insurance Other *

*Fees may be charged in accordance with MN Statute 144.2923 and Federal Rule 45 C.F.R. §164.524

INFORMATION

TO BE

RELEASED:

What Information

do you want

disclosed?

I want my records related to:

I want my records for dates of service:

Individual Report Options:

Any and All Records (includes ALL types of records at Allina Health) Other Records (specify type): _______________________________________

Special Disclosure

Permissions

Chemical Dependency/Substance Use Program Records Genetic Counseling Records

Wisconsin Records Only: Mental Health Records HIV Test Results

RELEASE

METHOD/FORMAT

Date Records are Needed (appointment date): _____ / _____ / _____ (NOTE: PLEASE ALLOW 7-10 DAYS FOR PROCESSING)

*NOTE: I acknowledge that by electing to receive my health information via email in a non-secure manner that the information will not be encrypted, and that it could be intercepted

and viewed by a third party. Allina Health is not responsible for unauthorized access of your health information while in transmission to the email address you designated above.

This authorization lasts for one year after the date you sign it unless you enter a different date or expiration here: _____ /_____ / _____

This authorization may be canceled in writing at any time. A cancellation will not change releases that happen before the cancellation. The

Allina Health Notice of Privacy Practice describes how to cancel (revoke) this authorization.

Allina Health will not restrict my treatment if I choose not to sign this authorization.

A photocopy/fax of this authorization will be treated in the same way as an original.

Allina Health records may include records that it received from other organizations. If these records have been used by Allina Health and filed in the

record Allina Health maintains about you, these records may be released with your Allina Health records.

Allina Health 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 Allina Health from

any and all liability resulting from a redisclosure by the recipient.

Federal Rule 42 CFR part 2 prohibits unauthorized disclosure of Substance Use Program Records

Your signature indicates that you have read and understand this form, and authorize release of your information as described above.

Patient/Legal Guardian Signature Date Authority to act on behalf of patient (attach document)

Billing Records* Community Pharmacy* Pathology Slides/Blocks* Radiology Images* (*Will be sent separately)

Clinic Record Set (office visit notes, lab, radiology report, med list, immunizations)

Hospital Record Set (history & physical, discharge summary, operative report, consultations, emergency records, lab, radiology report)

Discharge Summary/Note

History & Physical Exam

Operative Report

Consultations

Clinic/Progress Notes

Emergency/Urgent Care

Rehab Notes (PT/OT/ST/RT)

Home Health/Hospice

Laboratory Reports

Pathology Reports

Radiology Reports

EKG/ECHO

Immunization Record

Allergy Record

Medication Records

Allina Health My Account (MyChart) U.S. Mail (Paper) U.S. Mail (CD/DVD) Fax (Patient Care Only-See Above)

Non-Secure Email* (

to Patient Only-See Above) Secure Email : __________________________________________________________

Verbal (

no records will be sent) Pick Up at Allina Health Commons (by appt only) View Record

SR-10290 11/2019 allinahealth.org/medicalrecords

Directions for Completion of Form

Patient Information: Complete the entire section which identifies clearly and legibly all of the demographic information

specific to the patient (individual about whom information is being requested)

Release My Medical Records From: Check the first box if you would like your records released from an Allina Health

facility/provider. Check the second box if you are requesting your records be released from a non-Allina Health facility/provider.

When checking the Allina Health option, please specify the specific Allina Health location you are seeking information from.

Please be specific in your request. For example, United Hospital, St. Paul, MN; Buffalo Hospital, Buffalo, MN; Allina

Medical Clinic Shoreview, Shoreview, MN. If you do not identify a specific hospital or clinic (e.g. Allina Health), records

may be provided from ALL Allina Health hospitals or clinics where you have received care. Please see

allinahealth.org/medical records for a listing of Allina Health hospital and clinic locations and addresses.

Send My Medical Records To: Identify the full name/business, address, phone and contact information with the name

of the individual who is to receive the information. Please allow 7-10 days for all requests to be processed and sent to the

recipient.

Purpose For Release: Please identify why you need a copy of your record. This helps us to track and assign a priority

status to your request. It also informs us who may be responsible for the cost of records (where appropriate).

Information to Be Released: This section gives us the instructions for what information you want released. If you select

“Clinic Record Set” or “Hospital Record Set”, we will disclose the pertinent documents that are specific to that type of

patient care visit. This is typically what doctors’ offices, hospitals or other health care providers need to provide

information related to your care. If you select “any and all” records, your entire record will be provided for a specific visit

date or all dates. It is very helpful if you identify the date or range of dates, needed by the requestor. Please note record

types listed in the Special Disclosure Permissions section must be checked in order for them to be released.

Release Method: This tells us how you would like your information delivered. If you wish to view information prior to

selection of documents, please identify this on the authorization form and we will contact you to set up a viewing

appointment. Please note that viewing appointments are done at the Allina Health Corporate Office in Minneapolis. If

you wish information about you to be shared verbally or for an authorization to be on file for others to have access to your

medical information, please write this in this section (example: form on file for

access by my husband upon his specific

request). Please note: there are size limitations when emailing records.

Duration of the authorization, revocation and other information you need to know: This authorization will automatically

expire in 12 months unless you include a different date. You may indicate the authorization is valid “5 years”, “10 years”,

but there needs to be an ending date (do not use terms such as “lifetime” or “forever”). The authorization can be revoked

by your written direction to our organization.

Contact Information for Patient Record Copies

***Incoming medical records are not to be sent to this department***

Allina Health

Attn: Health Information/ROI – Mail Route 10203

PO Box 43

Minneapolis, MN 55440-0043

Phone:

612-262-2300

Fax: 612-262-2323

Email: [email protected]

Contact Information for Allina Health Pharmacy Charges Copies Allina Health Pharmacy – Mail Route 10807

Allina Health

PO Box 43

Minneapolis, MN 55440-0043

Phone:

612-262-5980

Fax: 612-262-5988

For a list of Allina Health locations and addresses, please visit allinahealth.org

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