NHS 2019 Release of Information Form English

This document provides the authorization for the release of information as indicated below. Information abour you cannot be released to others without your consent, except as authorized by law. Do not sign this form unless it is completed and is in your best interests.
Name: *
Date of Birth: *

Month Day Year
Date
Address

Address

Street Address Line 2

Zip
Phone #:
Information Released From:
Organization Name:
Specific Location/ Address:
Phone/Fax Number
Information Released To:
Organization Name:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Fax
Information to be Released:
For the following date(s) of treatment:
All Dates of Treatment
General Information: *

Immunizations Consultant Reports Progress Notes Laboratory Reports History and Physical/Initial Evaluation Inpatient Records X-ray Reports Treatment Plan
Requires Special Consent by Law for Release

Psychological Testing Psychotherapy Notes HIV/STD Testing Mental Health Records Substance Abuse Records*
*Records related to substance use disorder diagnosis and treatment are protected from disclosure by Federal Regulations governing confidentiality and substance use disorder patient records, 42 CFR Part 2, also known as "Part 2", and may only be disclosed by your Part 2 Provider with your written consent unless otherwise provided for by Part 2.
Release Instructions *

Patient Pick Up (ID will be requested at the time of pick up) Fax (Patient Care Only) Mail
Purpose of Release *

Legal* Other* Continuity of Care Personal Use or Review* Insurance/Benefits
* Fees may be charged in accordance with MN Statue 114.292 and Federal Rule 45 C.F.R. §164.524
This authorization lasts for one year after the date you sign it unless you enter a different date or expiration here: __________. This authorization may be canceled in writing at any time. A cancellation will not change releases that happen before the cancellation. The Neighborhood HealthSource Notice of Privacy Practice describes how to cancel (revoke) this authorization. Neighborhood HealthSource will not restrict my treatment if I choose not to sign this authorization. Neighborhood HealthSource cannot prevent re-disclosure of your information by the person or organization who receives your records under this authorization, and that information may not be covered by state and federal privacy protections after it is released. By signing this authorization, you release Neighborhood HealthSource from any and all liability resulting from a re-disclosure by the recipient. Your signature indicates that you have read and understand this form, and authorize release of your information as described above.
Signature of Patient / Client / Legal Guardian *

Clear
Relationship *
Date

Month Day Year
Date
Time

: Hour Minutes AM/PM Option
Please take photo of a Government Issued ID (example: Driver's License) *
Should be Empty:

Information Released From:

Information Released To:

Information to be Released: