Fillable Instructions for Minnesota Standard Consent Form to Release (City of Cottage Grove)

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Instructions for Minnesota Standard Consent Form to Release (City of Cottage Grove)

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The Instructions for Minnesota Standard Consent Form to Release (City of Cottage Grove) form is 3 pages long and contains:

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File type: PDF

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BROWSE CITY OF COTTAGE GROVE (MN) FORMS

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1
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Include your full and complete name. If you have a suffix
after your last name (Sr., Jr., III), please provide it in the
“last name” blank with your last name. If you used a
previous name(s), please include that information. If you
know your medical record or patient identification number,
please include that information. All these items are used to
identify your health information and to make certain that
only your information is sent.
2
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If there are questions about how this form was filled out,
this section gives the organization that will provide the
health information permission to speak to the person listed
in this section. Completing this section is optional.
3
|
In this section, state who is sending your health information.
Please be as specific as possible. If you want to limit what
is sent, you can name a specific facility, for example Main
Street Clinic. Or name a specific professional, for example
chiropractor John Jones. Please use the specific lines. Providing
location information may help make your request more clear.
Please print “All my health care providers” in this section
if you want health information from all of your health care
providers to be released.
4
|
Indicate where you would like the requested health
information sent. It is best to provide a complete mailing
address as not everyone will fax health information. A place
has been provided to indicate a deadline for providing the
health information. Providing a date is optional.
5
|
Indicate what health information you want sent. If you want
to limit the health information that is sent to a particular
date(s) or year(s), indicate that on the line provided.
For your protection, it is recommended that you initial instead
of check the requested categories of health information.
This helps prevent others from changing your form.
EXAMPLE: ____ All health information
If you select all health information, this will include any
information about you related to mental health evaluation
and treatment, concerns about drug and/or alcohol use,
HIV/AIDS testing and treatment, sexually transmitted
diseases and genetic information.
Important: There are certain types of health information
that require special consent by law.
Chemical dependency program information comes from
a program or provider that specifically assesses and treats
alcohol or drug addictions and receives federal funding. This
type of health information is different from notes about a
conversation with your physician or therapist about alcohol
or drug use. To have this type of health information sent,
mark or initial on the line at the bottom of page 1.
Psychotherapy notes are kept by your psychiatrist, psy-
chologist or other mental health professional in a separate
filing system in their office and not with your other health
information. For the release of psychotherapy notes,
you must complete a separate form noting only that
category. You must also name the professional who
will release the psychotherapy notes in section 3.
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|
Health information includes both written and oral information.
If you do not want to give permission for persons in section 3
to talk with persons in section 4 about your health information,
you need to indicate that in this section.
7
|
Please indicate the reason for releasing the health information.
If you indicate marketing, please contact the organization
in section 4 to determine if payment or compensation is
involved. If payment or compensation to the organization
is involved, indicate the amount.
8
|
This consent will expire one year from the date of your
signature, unless you indicate an earlier date or event.
Examples of an event are: “60 days after I leave the
hospital,” or “once the health information is sent.”
9
|
Please sign and date this form. If you are a legally
authorized representative of the patient, please sign, date
and indicate your relationship to the patient. You may be
asked to provide documents showing that you are the
patient or the patient’s legally authorized representative.
Instructions for Minnesota Standard Consent Form to Release Health Information
Important: Please read all instructions and information before completing and signing the form.
An incomplete form may not be accepted. Please follow the directions carefully. If you have any questions about the
release of your health information or this form, please contact the organization you will list in section 3.
This standard form was developed by the Minnesota Department of Health as required by the Minnesota Health Records Act of
2007. If completed properly, this form must be accepted by the health care organization(s), specific health care facility(ies), or
specific professional(s) identified in section 3.
A fee may be charged for the release of the health information.
The following are instructions for each section. Please type or print as clearly and completely as possible.
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This form was approved by the Commissioner of the Minnesota Department of Health on January 30, 2008.
JAN2008
Print Form
Patient information
First name _______________________ Middle name _______________________ Last name ____________________
Patient date of birth ___ /___ /
_______ Previous name(s) _________________________________________________
Home address
___________________________________________________________________________________
City
______________________________________________State ____________ Zip code _____________________
Daytime phone
_____________________________________E-mail address (optional)__________________________
Medical Record/patient ID number (optional)
____________________________________________________________
Contact for information about how this form was filled out (optional) :
I give permission for the organization(s) listed in section 3 permission to talk to
First name
________________________Last name ____________________________ about how this form was completed,
this person can be reached at: Daytime phone
_________________ E-mail address (optional) ________________________
I am requesting health information be released from at least one of the following:
Organization(s) name _____________________________________________________________________________
Specific health care facility or location(s)
_______________________________________________________________
Specific health care professional’s name(s)
_____________________________________________________________
I am requesting that health information be sent to:
Organization(s) name _____________________________________________________________________________
And/or person: First name
___________________________ Last name _____________________________________
Mailing address
_________________________________________________________________________________
City
_____________________________________________ State ____________ Zip code ______________________
Phone (optional)
___________________________________ Fax (optional) __________________________________
Information needed by (date) ___ / ___ / _______ (optional)
Information to be released
I
MPORTANT: indicate only the information that you are authorizing to be released.
___ Specific dates/years of treatment
_________________________________________________________________
___ All health information
(see description in instructions for what is included)
OR to only release specific portions of your health information, indicate the categories to be released:
___ History/Physical
___ Laboratory report
___ Emergency room report
___ Surgical report
___ Medications
___ Other information or instructions
_________________________________________________________________
The following information requires special consent by law. Even if you indicate all health information, you must
specifically request the following information in order for it to be released:
___ Chemical dependency program
(see definition in instructions)
___ Psychotherapy notes
(this consent cannot be combined with any other; see instructions)
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mm dd yyyy
Minnesota Standard Consent Form to Release Health Information
PAGE 1 OF 2
mm dd yyyy
___ Mental health
___ Discharge summary
___ Progress notes
___ Care plan
___ Immunizations
___ HIV/AIDS testing
___ Radiology report
___ Radiology image(s)
___
Photographs, video, digital or other images
___
Billing records
JAN2008
This form was approved by the Commissioner of the Minnesota Department of Health on January 30, 2008.
Health information includes written and oral information
By indicating any of the categories in section 5, you are giving permission for written information to be released and for
a person in section 3 to talk to a person in section 4 about your health information.
If you do not want to give your permission for a person in section 3 to talk to a person in section 4 about your health
information, indicate that here (check mark or initials) ______
Reason(s) for releasing information
___ Patient’s request
___ Review patient’s current care
___ Treatment/continued care
___ Payment
___ Insurance application
___ Legal
___ Appeal denial of Social Security Disability income or benefits
___ Marketing purposes (payment or compensation involved?
NO YES, amount _________________________ )
___ Other (please explain)
_________________________________________________________________________
I understand that by signing this form, I am requesting that the health information specified in Section 5 be sent to the third
party named in section 4 above.
I may stop this consent at any time by writing to the organization(s), facility(ies) and/or professional(s) named in section 3.
If the organization, facility or professional named in section 3 has already released health information based on my consent,
my request to stop will not work for that health information.
I understand that when the health information specified in section 5 is sent to the third party named in section 4 above, the
information could be re-disclosed by the third party that receives it and may no longer be protected by federal or state privacy laws.
I understand that if the organization named in section 4 is a health care provider they will not condition treatment, payment,
enrollment or eligibility for benefits on whether I sign the consent form.
If I choose not to sign this form and the organization named in section 4 is an insurance company, my failure to sign will not
impact my treatment; I may not be able to get new or different insurance; and/or I may not be able to get insurance payment
for my care.
This consent will end one year from the date the form is signed unless I indicate an earlier date or event here:
Date ___ / ___ / ______ Or specific event _______________________________________________________________
Patient’s signature ________________________________________________________ Date ___ /___ /______
Or legally authorized representative’s signature ______________________________________ Date ___ /___ /______
Representative’s relationship to patient (parent, guardian, etc.)
______________________________________________
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Minnesota Standard Consent Form to Release Health Information
Patient’s name _______________________________________________________ PAGE 2 OF 2
JAN2008
This form was approved by the Commissioner of the Minnesota Department of Health on January 30, 2008.
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Instructions for Minnesota Standard Consent Form to Release (City of Cottage Grove)

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Completed 21 January 2021

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