Get Patient Authorization For Release Of Protected - Healthpartners

Filling out the Patient Authorization for Release of Protected Information form is an important step in managing your health records. This guide provides a clear, step-by-step approach to completing the form online, ensuring you understand each section.

Follow the steps to complete the authorization form with ease.

1. Use the ‘Get Form’ button to access the Patient Authorization for Release of Protected Information form and open it in your preferred format.
2. Begin filling out the patient information section. Enter your full name, date of birth, and daytime telephone number. Provide your complete address, including city, state, and zip code.
3. Identify the source of the health information to be released. Check the appropriate box indicating if it is from HealthPartners Clinics or another provider, and ensure you include the complete address of the other provider or organization.
4. Specify the purpose of disclosure by checking one or more of the available options. Options include continuity of care, consultation, legal purposes, insurance, or personal reasons. You can also provide additional details in the provided space.
5. Select the specific health information to be released. Choose from options such as the entire health record, office notes, laboratory results, and more. Carefully consider which records are relevant to your needs.
6. Indicate if you wish to exclude any sensitive information, such as behavioral health records or HIV-related information, by marking the respective boxes.
7. Choose the method of delivery for the information by selecting from options such as mail, fax, or in-person pickup. Make sure to note if a picture ID is required for in-person pickups.
8. Set the expiration date for the authorization. This date should not exceed twelve months from the date of signing unless permitted by law.
9. Read through the statements regarding your rights concerning the authorization. Ensure you understand that you can revoke this authorization at any time in writing.
10. Sign the form, including the date of signature. If applicable, have a representative sign on your behalf and include their relationship to you.
11. Provide the signature and name of a witness if required. Ensure all information is accurate before finalizing the form.
12. Once you have completed the form, save your changes and choose whether to download, print, or share the completed document as needed.

Complete your Patient Authorization for Release of Protected Information form online today for efficient processing.