ATTENTIVE HOME CARE
Instructions for Minnesota Standard Consent Form to Release Health Information
Important: Please read all instructions and information before completing and signing the form.
An incomplete form might not be accepted. Please follow the directions carefully. If you have any questions about the release of your health information or this form, please contact the organization you will list in section 3.
This standard form was developed by the Minnesota Department of Health as required by the Minnesota Health Records Act of 2007, Minnesota Statutes, section 144.292, subdivision 8. The form must be accepted by a Minnesota provider as a legally enforceable request under the Minnesota Health Records Act. If completed properly, this form must be accepted by the health care organization(s), specific health care facility(ies), or specific professional(s) identified in section 3.
A fee may be charged for the release of the health information.
Include your full and complete name. If you have a suffix after
your last name (Sr., Jr., III), please provide it in the “last name”
blank with your last name. If you used a previous name(s), please
include that information. If you know your medical record or
patient identification number, please include that information.
All these items are used to identify your health information and
to make certain that only your information is sent.
If there are questions about how this form was filled out, this section gives the organization that will provide the health information permission to speak to the person listed in this section. Completing this section is optional.
In this section, state who is sending your health information. Please be as specific as possible. If you want to limit what is sent, you can name a specific facility, for example Main Street Clinic. Or name a specific professional, for example chiropractor John Jones. Please use the specific lines. Providing location information may help make your request more clear. Please print “All my health care providers” in this section if you want health information from all of your health care providers to be released.
Indicate where you would like the requested health information
sent. It is best to provide a complete mailing address as not
everyone will fax health information. A place has been provided to indicate a deadline for providing the health information. Providing a date is optional.
Indicate what health information you want sent. If you want to
limit the health information that is sent to a particular date(s)
or year(s), indicate that on the line provided. For your protection, it is recommended that you initial instead of check the requested categories of health information.
This helps prevent others from changing your form.
EXAMPLE: All health information
If you select all health information, this will include any information about you related to mental health evaluation and treatment, concerns about drug and/or alcohol use, HIV/AIDS testing and treatment, sexually transmitted diseases and genetic information.
Important: There are certain types of health information that
require special consent by law.
Chemical dependency program information comes from a
program or provider that specifically assesses and treats alcohol
or drug addictions and receives federal funding. This type of
health information is different from notes about a conversation
with your physician or therapist about alcohol or drug use. To
have this type of health information sent, mark or initial on the
line at the bottom of page 1.
Psychotherapy notes are kept by your psychiatrist, psychologist
or other mental health professional in a separate filing system
in their office and not with your other health information. For
the release of psychotherapy notes, you must complete
a separate form noting only that category. You must also
name the professional who will release the psychotherapy
notes in section 3.
Health information includes both written and oral information. If you do not want to give permission for persons in section 3 to talk with persons in section 4 about your health information, you need to indicate that in this section.
Please indicate the reason for releasing the health information. If you indicate marketing, please contact the organization in section 4 to determine if payment or compensation is involved. If payment or compensation to the organization is involved, indicate the amount.
This consent will expire one year from the date of your signature,
unless you indicate a different date or event. Examples of an
event are: “60 days after I leave the hospital,” or “once the health
information is sent.”
Please sign and date this form. If you are a legally authorized
representative of the patient, please sign, date and indicate
your relationship to the patient. You may be asked to provide
documents showing that you are the patient or the patient’s
legally authorized representative.
Minnesota Standard Consent Form to Release Health Information
I give permission for the organization(s) listed in section 3 permission to talk to
about how this form was completed, this person can be reached at:
And/or person:
OR to only release specific portions of your health information, indicate the categories to be released:
The following information requires special consent by law. Even if you indicate all health information, you must specifically request the following information in order for it to be released:
By indicating any of the categories in section 5, you are giving permission for written information to be released and for a person in section 3 to talk to a person in section 4 about your health information.
I understand that by signing this form, I am requesting that the health information specified in Section 5 be sent to the third party named
in section 4.
I may stop this consent at any time by writing to the organization(s), facility(ies) and/or professional(s) named in section 3.
If the organization, facility or professional named in section 3 has already released health information based on my consent, my request
to stop will not work for that health information.
I understand that when the health information specified in section 5 is sent to the third party named in section 4, the information could
be re-disclosed by the third party that receives it and may no longer be protected by federal or state privacy laws.
I understand that if the organization named in section 4 is a health care provider they will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign the consent form.
If I choose not to sign this form and the organization named in section 4 is an insurance company, my failure to sign will not impact my
treatment; I may not be able to get new or different insurance; and/or I may not be able to get insurance payment for my care.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of any individual or family member of the individual, except as specifically allowed by this law
