A medical records (including mental health records) release authorization to obtain records for use in a dissolution proceeding.
Release Medical Records From
Category:
State:
Minnesota
Control #:
MN-8555D
Format:
Word;
Rich Text
Instant download
Description
How to fill out Minnesota Authorization To Release Medical And Mental Health Information?
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FAQ
A description of the information that will be used/disclosed. The purpose for which the information will be disclosed. The name of the person or entity to whom the information will be disclosed. An expiration date or expiration event when consent to use/disclose the information is withdrawn.
The patient's legal name, date of birth, gender, Social Security number, address, telephone number, guarantor, subscriber, or next-of-kin are key identifying elements that assist in establishing the proper individual.
A: You must write the form in plain language and include the following parts:A description of the information that you will use or disclose and the purpose of it.The name(s) or other identification of the person (or class of persons) authorized to request the use or disclosure of PHI.More items...
Elements of a release formPatient information. Naturally, the release should require the patient's information so it's clear who the form refers to.Receiving party's information.Information to be shared.Purpose of the release.Expiration of authorization.Disclaimers.Date and signature.
You should specify so that your doctor knows what to release. If you want to release everything, then include this language: "I authorize the release of my complete health history (including all information related to HIV or AIDS, mental health care, communicable diseases, or treatment of alcohol and drug abuse)."
