John A. Haugen Associates Obstetrics & Gynegology

For Immediate Assistance Call 952.927.6561

  • Our Providers
    • About Haugen OB/GYN
    • Our Doctors
    • Our Nurse Practitioners
  • Services
    • Obstetrics
    • Gynecology
    • Infertility
    • Ultrasound
    • Bone Density Scans
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    • Edina
    • Minneapolis
    • Plymouth
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  • Our Providers
    • About Haugen OB/GYN
    • Our Doctors
    • Our Nurse Practitioners
  • Services
    • Obstetrics
    • Gynecology
    • Infertility
    • Ultrasound
    • Bone Density Scans
    • Virtual Visits
  • Locations
    • Edina
    • Minneapolis
    • Plymouth
  • What’s New
    • Hot Topics
  • Patient Forms
    • Medical Release & Request
    • Hospital Registration
  • Patient Resources
    • Abbott Northwestern Hospital
    • Fairview Southdale Hospital
    • Good Faith Estimate Notice
    • Helpful Links
    • Patient Portal
    • Pay Your Bill
    • Notice of Privacy Practices
    • Financial Policy
    • Price Transparency

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Authorization For Release Of Medical Information

Authorization For Release Of Medical Information

"*" indicates required fields

Patient Name*
Previous Name(s)
MM slash DD slash YYYY
Date of Birth:

Release my records FROM:
Where are you releasing your records from?
Their Address*

Send my records TO:
Where are you releasing your records TO?
Haugen OB/GYN
Their Address*

Types Of Records*
Reason For Request*
(please record the purpose of the disclosure or check patient request):

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
MM slash DD slash YYYY
Date
Print Name
MM slash DD slash YYYY
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

Let us know what we can help you with:

If you have any questions or comments regarding this information, please feel free to contact our office at 952-927-6561.

Locations:

Edina

3400 W. 66th Street
Suite 385
Edina, MN 55435
  • 952-927-6561
  • 952-927-6569

Minneapolis

801 Nicollet Mall
Suite 400
Minneapolis MN 55402
  • 612-333-2503
  • 612-333-7575

Plymouth

2805 Campus Dr
Suite 315
Plymouth MN 55441
  • 763-577-7460
  • 763-577-7461

PATIENT RESOURCES

QUICK LINKS

Patient Portal
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