Fillable Authorization for Release of Protected Health Information

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Authorization for Release of Protected Health Information

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1901 CONNECTICUT AVE. S
SARTELL, MN 56377
MAIN 320-259-4100
FAX 320-257-5522
WWW.STCLOUDORTHOPEDICS.COM
Authorization for Release of Protected Health Information
Patient Name
Date of Birth
Chart Number
I authorize: To release my health information to:
(NAME AND ADDRESS) (NAME AND ADDRESS)
St. Cloud Orthopedics
1901 Connecticut Ave. S
Sartell, MN 56377
Fax #: 320-257-5522
Purpose of Release: Extent of Information to Release:
PATIENT’S OWN REVIEW
ALL DATES OF TREATMENT
CONTINUING CARE
DATES OF TREATMENT FROM
INSURANCE CLAIM
______________ TO _______________
LITIGATION
(MONTH/DAY/YEAR) (MONTH/DAY/YEAR)
OTHER_____________________________
ONLY FROM DR._____________________
AREA OF TREATMENT:_______________
OTHER: _____________________________
Information to be released:
(Please check all that apply)
PHYSICIAN NOTES
PHYSICAL THERAPY NOTES
HOSPITAL/SURGICAL REPORTS
LABORATORY REPORTS
X-RAY/DIAGNOSTIC REPORTS
ITEMIZED BILLING STATEMENTS
X-RAY/DIAGNOSTIC FILMS
OTHER___________________________
I understand that any documentation of substance abuse (drugs or alcohol), psychological or psychiatric
conditions, sexually transmitted diseases, and HIV/AIDS will be released as part of my record UNLESS I
INITIAL BELOW:
DO NOT RELEASE:
(INITIAL TO PROHIBIT RELEASE)
DRUG/ALCOHOL ABUSE
MENTAL HEALTH
STDs
HIV/AIDS
By signing below, I understand the following:
Once my information is released, my records may not be protected under federal privacy regulations, and may be
subject to re-disclosure. I may refuse to sign this authorization and that my refusal to sign will not affect my ability
to obtain treatment. I may revoke this authorization at any time by writing to St. Cloud Orthopedics, Attn: ROI
Dept., but revocation will not apply to information that has already been released. This authorization will
automatically expire after one year from the signature date below unless an earlier date is specified
here____________________.
SIGNATURE OR MARK OF PATIENT, PARENT OF MINOR, OR LEGAL REPRESENTATIVE
(CAN’T BE A DIGITAL SIGNATURE)
TODAY’S DATE
DECLARE LEGAL AUTHORITY TO SIGN AND ATTACH DOCUMENTATION IF APPROPRIATE
WITNESS SIGNATURE REQUIRED IF PATIENT UNABLE TO SIGN BUT USES X OR A MARK
TODAY’S DATE
The requesting party may be subject to a charge for the release of information. Please contact the Release of Information
Department at St. Cloud Orthopedics for fee information.
Mak/forms/Authorization and Release Form (Updated: 8/2011)
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Authorization for Release of Protected Health Information

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Completed 14 October 2020

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