Allina Health 2019-2026

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. authorization and that information may not be covered by state and federal privacy protections after it is released. By signing this Your signature indicates that you have read and understand this form and authorize release of your information as described above. ALLINA HEALTH AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION PATIENT INFORMATION NAME DATE OF BIRTH Address Day Phone City State Zip Clinic/Hospital/Health Care Provider Who has the information you want released Please list the specific Hospital and/or clinic. Receiving Party Where do you want the information sent Who may have the information Fax Number URGENT PATIENT CARE ONLY Information to be Released What do you want sent or released Check the appropriate box. Authorization and that information may not be covered by state and federal privacy protections after it is released. By signing this Your signature indicates that you have read and understand this form and authorize release of your information as described above. Patient/Legal Guardian Signature SR-10290 10/2015 Date Authority to act on behalf of patient attach document 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 who information is being requested for Clinic/Health care Provider Identify which Allina Health hospital or clinic you are seeking information from or to be sent to. If you want to include images and billing records check those boxes. Only records types checked below Discharge summary/note Radiology reports Emergency record s Medication records History physical exam Rehab records PT/OT/ST Immunization/allergy record Chemical dependency/ Operative report Laboratory reports Pathology reports Substance abuse records Consultations Progress notes/clinic notes Mental health records Pathology slides/blocks Other records specify record type s OPTIONAL Limits - Disclose only records related to following Date s of service/ injury or illness Release Instructions Date information is needed NOTE PLEASE ALLOW 7-10 DAYS FOR PROCESSING How and When do you want the information Release Method / Format requested check one Paper CD/DVD View my Record Fax patient care only Continuing Care Information released by Nursing Station/Department verbal and paper Purpose of Release Why is it needed Verbal Yes No Transfer of care Social security appeal Insurance application Personal use or review Insurance payment/claim Litigation/legal determination Other Fees may be charged in accordance with MN Statute 144. 292 and Federal Rule 45 C. F. R. 164. 524 This authorization lasts for one year after the date you sign it unless you enter a different date or expiration here 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. Routine Record Sets indicate date s of service Clinic office visit lab radiology medicines immunizations Hospital history and physical discharge summary operative report consultations emergency laboratory radiology Billing Records Copies of Films/Images Community Pharmacy Charges Any and all records includes ALL types of record listed below. If you want to include images and billing records check those boxes. Only records types checked below Discharge summary/note Radiology reports Emergency record s Medication records History physical exam Rehab records PT/OT/ST Immunization/allergy record Chemical dependency/ Operative report Laboratory reports Pathology reports Substance abuse records Consultations Progress notes/clinic notes Mental health records Pathology slides/blocks Other records specify record type s OPTIONAL Limits - Disclose only records related to following Date s of service/ injury or illness Release Instructions Date information is needed NOTE PLEASE ALLOW 7-10 DAYS FOR PROCESSING How and When do you want the information Release Method / Format requested check one Paper CD/DVD View my Record Fax patient care only Continuing Care Information released by Nursing Station/Department verbal and paper Purpose of Release Why is it needed Verbal Yes No Transfer of care Social security appeal Insurance application Personal use or review Insurance payment/claim Litigation/legal determination Other Fees may be charged in accordance with MN Statute 144. 292 and Federal Rule 45 C. F. R. 164. 524 This authorization lasts for one year after the date you sign it unless you enter a different date or expiration here 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.