This form is a consent to the release of medical history. The patient authorizes the release of his/her medical history to the specified party within the consent release form. The form also provides that all prior authorizations are cancelled.
Consent Release Form With More Costly Wrapping In Hennepin
State:
Multi-State
County:
Hennepin
Control #:
US-00460
Format:
Word;
Rich Text
Instant download
Description
Free preview
Form popularity
FAQ
Apply for benefits Apply for economic benefits whenever, wherever. Apply online or call 612-596-1300 Monday through Friday, 9 a.m. to 4 p.m.
Call 612-348-3000, Monday through Friday, 8 a.m. to p.m.
How to submit forms and documents and update your information Update information and upload documents to InfoKeep. Upload to MNbenefits. Fax to 612-288-2981. Mail to: Hennepin County Human Services Department. P.O. Box 107. Minneapolis, MN 55440.
Who do I report a change to? If someone in your household gets MA, report a change to your county or tribal agency. If no one in your household gets MA, but someone in your household does get MinnesotaCare, report a change to DHS Health Care Consumer Support at 800-657-3672 or 651-297-3862.
You may request your records on paper or in an electronic format. Fax your release form at 612-873-1516. In-person: For form drop-off, please leave your form in the black box near the office door of the Medical Records Office at Hennepin Healthcare.
Hennepin Healthcare System is the state's largest Medicaid provider system and safety-net trauma hospital in Minnesota, proudly serving the most complex populations from throughout the state.
For same day processing, you must call Hennepin County Vital Records directly at 612-348-8240 before pm (CST).
In 2018, HCMC became Hennepin Healthcare.