Health Information Release Authorization Form
Please complete this form to authorize the release of your health information.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email Address
*
example@example.com
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Information Released From:
Please provide the Health Information is being released from below.
Who has the Information to be Released?
*
Summit Orthopedics, LTD
Minnesota Occupational Health
Health Information Released To:
Please Provide the Health Information to be released below.
Name or Third-Party Org/Clinic
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Specific Date/Year of the Treatment
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Specific Date(s) or Year(s) of the Treatment
Type of Health Information to be Released
*
Images
Doctors Notes
Therapy Notes
Operative Report
Surgery Chart
Injection Notes
Lab Reports
Radiology Reports
EMG Reports
Billing Statement
Other
Any Additional Information Regarding This Request (describe specifically):
Delivery Method
*
U.S. Mail
Email
Fax
In-Person Pickup at the Summit Office Location Noted Below:
If Picking Up, Which Summit Office Location?
Purpose for Release
*
Personal Use
Continued Care
Disability
Insurance
Legal
Workers Compensation
Other
Authorization
Please read carefully and sign below to continue
I understand that by signing this form, I am requesting that the health information specific be sent to the third party listed above. I understand that I may revoke this request at any time in writing to summit orthopedics. The revocation will not apply to records already released. Summit Orthopedics will not condition treatment on whether I sign this authorization. I understand that the information can be re-disclosed by the third-party list above and once received it may no longer be protected by federal or state privacy laws. I understand that records released may include information received from other third parties. I am aware that some requests may incur a fee as allowed by law. This Authorization will end once a year from the date the form is signed. If you want to end on a sooner date, enter the date below.
*
This Authorization will end once a year from the date the form is signed. If you want to end on a sooner date, enter the date below.
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Print Name of Patient or Representative
*
First Name
Last Name
Signature
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship/Authority
If you are not the patient, list your relationship/authority to sign on patients behalf (examples: parent, legal representative, power of attorney for healthcare, etc.). Representatives signing this form on behalf of a patient may be requested to submit documentation of the relationship/authority.
Name
First Name
Last Name
Relationship
Signature
Submit Authorization
Submit Authorization
Should be Empty: