AUTHORIZATION TO RELEASE PHI

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
SUMMIT BEHAVIORAL HEALTH

2115 County Road D East, Suite C-100, Maplewood, MN 55109

PHONE: 6513587020 FAX: 612-293-6742
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mobile Phone Number *

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
THIS WILL AUTHORIZE SUMMIT BEHAVIORAL HEALTH TO (CHOOSE ONE): *

RELEASE TO REQUEST FROM EXCHANGE WITH
NAME/ORGANIZATION: *
ADDRESS:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PHONE NUMBER:

Area Code Phone Number
FAX NUMBER *

Area Code Phone Number
THE FOLLOWING INFORMATION IS TO BE RELEASED (CHECK APPROPRIATE BOX OR CHECK ALL RECORDS): *

HOSPITAL/CLINIC SUMMARIES MEDICATION HISTORY PROGRESS NOTES ALL RECORDS (TO INCLUDE PSYCHIATRIC, MENTAL HEALTH, AND CHEMICAL DEPENDENCY)
ALL DATES *

ALL DATES SPECIFIC DATES
SPECIFIC DATES (IF APPLICABLE):
I AM REQUESTING THIS INFORMATION BE RELEASED FOR THE FOLLOWING PURPOSES: *

CONTINUITY /COORDINATION OF CARE WITH ANOTHER PROVIDER ATTORNEY REVIEW INSURANCE CLAIM/APPLICATION OTHER
I UNDERSTAND I MAY REVOKE THIS AUTHORIZATION AT ANY TIME TO THE ADDRESS LISTED AT THE TOP OF THIS FORM. I UNDERSTAND THAT THE REVOCATION WILL NOT APPLY TO INFORMATION THAT HAS ALREADY BEEN RELEASED IN RESPONSE TO THIS AUTHORIZATION. I UNDERSTAND THAT TREATMENT MAY NOT BE CONDITIONED ON MY AGREEMENT TO SIGN THIS AUTHORIZATION.THIS AUTHORIZATION WILL AUTOMATICALLY EXPIRE ONE YEAR FROM THE DATE OF MY SIGNATURE. I UNDERSTAND THAT ONCE INFORMATION IS RELEASED PURSUANT TO THIS AUTHORIZATION WE CANNOT PREVENT THE REDISCLOSURE TO ANOTHER THIRD PARTY. A COPY OF THIS AUTHORIZATION WILL BE CONSIDERED AS VALID AS THE ORIGINAL.
SIGNATURE OF PATIENT/AUTHORIZED PERSON *

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Date *

Month Day Year
Date
SIGNATURE OF AUTHORIZED PERSON

Clear
Date

Month Day Year
Date
REASON PERSON IS UNABLE TO SIGN:

MINOR DECEASED OTHER
Should be Empty:

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

SUMMIT BEHAVIORAL HEALTH

2115 County Road D East, Suite C-100, Maplewood, MN 55109

PHONE: 6513587020 FAX: 612-293-6742