Patient Authorization for Disclosure of Protected Health Information

Patient Name*

First Middle Last

Previous Name(s)

First Middle Last

Patient Date of Birth:*

Date of Birth:

Send my records FROM:*

Where are you releasing your records FROM?

If you are requesting records from Mayo to be sent to our clinic we will need your Mayo MRN number in order for them to process.

Clinic Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Provider Name*

Clinic Phone

Clinic Fax

Send my records TO:*

Where are you releasing your records TO?

Haugen OB/GYN

City State ZIP Code

Fax

Phone

Types Of Records*

All Health Information (not including billing)

Other:

Office Notes

Radiology Reports

Lab Reports

Operative Reports

Hospital Reports

Billing Statement

Pathology Reports

Reason For Request*

(please record the purpose of the disclosure or check patient request):

Personal Use

Disability

Insurance

Legal

Workers Compensation

Continuing Care

I Understand That By Signing The Below:

I may revoke this authorization at any time by notifying i-Health in writing. If I revoke this authorization, i-Health will no longer use or disclose my health information for the reasons covered by this authorization, except to the extent it has already relied upon this authorization.
By authorizing the release of my protected health information, the health information may no longer be protected and has the potential to be re-disclosed.
There may be a fee for release of this information and I may be responsible for that fee.
I am authorizing the release of my personal protected health information from any i-Health facility, unless otherwise specified above.
Treatment will not be denied to me if I do not sign this form.
If I provided an email address in section 3, I understand that the requested records will be sent via encrypted email, or it may be sent to a patient portal.
i-Health is a multispecialty practice including, and without limitation, the clinic above. Your i-Health record will be released, unless you otherwise specify in writing

Signed By

Patient

Patient Representative

This authorization will expire one year from the date I sign this form, unless specified:

Date

Signature

Print Name

Date

*If this form is signed by someone other than the patient, legal documentation showing guardianship or authorization must be on file or presented with this form

Patient Authorization for Disclosure of Protected Health Information

Authorization For Release Of Medical Information

I Understand That By Signing The Below:

Edina

Minneapolis

Plymouth

PATIENT RESOURCES