Allina Hospitals And Clinics Form PDF Details

The Allina Hospitals and Clinics medical records authorization form is a HIPAA-compliant document that allows patients and authorized representatives to request the release of protected health information (PHI) from Allina Health facilities. This form is required whenever you need Allina Health to share your medical records with another party, including other healthcare providers, insurance companies, attorneys, or yourself.

Patients use this form for a variety of purposes: continuing medical care with a new provider, obtaining personal copies of health records, supporting insurance claims, fulfilling legal requirements, and meeting employment-related health documentation needs. Authorized representatives such as legal guardians, power of attorney holders, or personal representatives of deceased patients may also complete this form on behalf of the patient.

The authorization covers a wide range of medical documents: clinic and hospital record sets, billing records, radiology images, laboratory and pathology reports, immunization and allergy records, discharge summaries, progress notes, and specialized records such as mental health records, substance use program records, and genetic counseling records. You can specify exact date ranges and choose your preferred delivery method, whether by electronic means, mail, fax, or pickup.

The form complies with Minnesota state law and federal HIPAA privacy regulations. Authorization typically remains valid for one year unless you specify a shorter period or revoke it in writing. Once records are released, Allina Health cannot control subsequent redisclosure by the recipient. For similar forms, see the United Healthcare release of information form, the Aspen Dental health information release, or the medical records request form.

QuestionAnswer
Form NameAllina Hospitals And Clinics Authorization Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out5-10 minutes
PurposeAuthorize release of patient health records
Governing lawHIPAA and Minnesota privacy statutes
Other namesallina authorization form, allina health authorization form, allina health release of information form, allina authorization to release information, form 10290

Form Preview Example

ALLINA HEALTH

AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION

Internal Use

Only

Completed By Initials : ___________ Date: ___________

 

 

Patient name

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

PATIENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION

Street Address

 

 

 

 

 

 

 

 

 

Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

Zip Code

 

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Allina Health (optional: specify location or provider below):

 

 

OR

 

Hospital/Clinic/Provider (required: specify name below)

 

RELEASE MY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

Phone Number

 

 

 

 

 

 

RECORDS FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**check one option

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

 

Zip Code

 

Fax Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEND MY MEDICAL

Person/Business/Hospital/Clinic

 

 

 

 

 

Phone Number

 

 

 

Fax Number

 

 

 

RECORDS TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**address field is

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

City

 

 

 

 

State

Zip Code

 

required

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PURPOSE FOR

Continuing Care

Personal Use/Review *

Litigation/Legal *

Insurance Application *

Insurance Payment/Claim

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RELEASE

Social Security Disability *

Social Security Appeal

Disability Insurance

Other *

 

 

 

 

 

 

 

 

 

 

 

 

 

*Fees may be charged in accordance with MN Statute 144.2923 and Federal Rule 45 C.F.R. §164.524

I want my records related to:

 

 

INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO BE

I want my records for dates of service:

 

 

 

 

 

 

 

 

 

 

RELEASED:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Billing Records*

Community Pharmacy*

Pathology Slides/Blocks*

Radiology Images*

(*Will be sent separately)

 

 

 

 

 

What Information

Clinic Record Set (office visit notes, lab, radiology report, med list, immunizations)

 

 

 

 

Hospital Record Set (history & physical, discharge summary, operative report, consultations, emergency records, lab, radiology report)

 

 

do you want

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

disclosed?

Individual Report Options:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Discharge Summary/Note

Clinic/Progress Notes

 

 

Laboratory Reports

Immunization Record

 

 

 

History & Physical Exam

Emergency/Urgent Care

Pathology Reports

Allergy Record

 

 

 

Operative Report

 

 

Rehab Notes (PT/OT/ST/RT)

Radiology Reports

Medication Records

 

 

 

Consultations

 

 

Home Health/Hospice

 

 

EKG/ECHO

 

 

 

 

 

Any and All Records (includes ALL types of records at Allina Health)

Other Records (specify type): _______________________________________

 

 

 

Chemical Dependency/Substance Use Program Records

Genetic Counseling Records

 

 

 

 

Special Disclosure

 

 

 

 

Permissions

Wisconsin Records Only:

Mental Health Records

HIV Test Results

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Records are Needed (appointment date): _____ / _____ / _____

(NOTE: PLEASE ALLOW 7-10 DAYS FOR PROCESSING)

 

 

RELEASE

Allina Health My Account (MyChart)

U.S. Mail (Paper)

U.S. Mail (CD/DVD)

Fax (Patient Care Only-See Above)

 

 

METHOD/FORMAT

 

 

Non-Secure Email* (to Patient Only-See Above)

Secure Email : __________________________________________________________

 

 

 

 

 

 

Verbal (no records will be sent)

 

 

 

Pick Up at Allina Health Commons (by appt only)

View Record

 

 

 

*NOTE: I acknowledge that by electing to receive my health information via email in a non-secure manner that the information will not be encrypted, and that it could be intercepted

 

 

 

and viewed by a third party. Allina Health is not responsible for unauthorized access of your health information while in transmission to the email address you designated above.

 

 

 

 

 

 

 

 

 

 

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

 

 

Allina Health Notice of Privacy Practice describes how to cancel (revoke) this authorization.

 

 

 

 

 

Allina Health will not restrict my treatment if I choose not to sign this authorization.

 

 

 

 

 

 

 

A photocopy/fax of this authorization will be treated in the same way as an original.

 

 

 

 

 

 

 

Allina Health records may include records that it received from other organizations. If these records have been used by Allina Health and filed in the

 

 

record Allina Health maintains about you, these records may be released with your Allina Health records.

 

 

 

 

Allina Health cannot prevent redisclosure 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 Allina Health from

 

 

any and all liability resulting from a redisclosure by the recipient.

 

 

 

 

 

 

 

 

 

 

Federal Rule 42 CFR part 2 prohibits unauthorized disclosure of Substance Use Program Records

 

 

 

 

Your signature indicates that you have read and understand this form, and authorize release of your information as described above.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient/Legal Guardian Signature

 

 

 

 

 

Date

 

 

Authority to act on behalf of patient (attach document)

SR-10290 11/2019

 

 

 

 

allinahealth.org/medicalrecords

 

 

 

Directions for Completion of Form

Patient Information: Complete the entire section which identifies clearly and legibly all of the demographic information specific to the patient (individual about whom information is being requested)

Release My Medical Records From: Check the first box if you would like your records released from an Allina Health facility/provider. Check the second box if you are requesting your records be released from a non-Allina Health facility/provider. When checking the Allina Health option, please specify the specific Allina Health location you are seeking information from. Please be specific in your request. For example, United Hospital, St. Paul, MN; Buffalo Hospital, Buffalo, MN; Allina Medical Clinic Shoreview, Shoreview, MN. If you do not identify a specific hospital or clinic (e.g. Allina Health), records may be provided from ALL Allina Health hospitals or clinics where you have received care. Please see allinahealth.org/medical records for a listing of Allina Health hospital and clinic locations and addresses.

Send My Medical Records To: Identify the full name/business, address, phone and contact information with the name of the individual who is to receive the information. Please allow 7-10 days for all requests to be processed and sent to the recipient.

Purpose For Release: Please identify why you need a copy of your record. This helps us to track and assign a priority status to your request. It also informs us who may be responsible for the cost of records (where appropriate).

Information to Be Released: This section gives us the instructions for what information you want released. If you select “Clinic Record Set” or “Hospital Record Set”, we will disclose the pertinent documents that are specific to that type of patient care visit. This is typically what doctors’ offices, hospitals or other health care providers need to provide information related to your care. If you select “any and all” records, your entire record will be provided for a specific visit date or all dates. It is very helpful if you identify the date or range of dates, needed by the requestor. Please note record types listed in the Special Disclosure Permissions section must be checked in order for them to be released.

Release Method: This tells us how you would like your information delivered. If you wish to view information prior to selection of documents, please identify this on the authorization form and we will contact you to set up a viewing appointment. Please note that viewing appointments are done at the Allina Health Corporate Office in Minneapolis. If you wish information about you to be shared verbally or for an authorization to be on file for others to have access to your medical information, please write this in this section (example: form on file for access by my husband upon his specific request). Please note: there are size limitations when emailing records.

Duration of the authorization, revocation and other information you need to know: This authorization will automatically expire in 12 months unless you include a different date. You may indicate the authorization is valid “5 years”, “10 years”, but there needs to be an ending date (do not use terms such as “lifetime” or “forever”). The authorization can be revoked by your written direction to our organization.

Contact Information for Patient Record Copies

***Incoming medical records are not to be sent to this department***

Allina Health

Attn: Health Information/ROI – Mail Route 10203

PO Box 43

Minneapolis, MN 55440-0043

Phone: 612-262-2300

Fax: 612-262-2323

Email: MedicalRecords@allina.com

Contact Information for Allina Health Pharmacy Charges Copies Allina Health Pharmacy – Mail Route 10807

Allina Health

--------------------------------------------

PO Box 43

 

 

Plate: Black

Minneapolis, MN 55440-0043

 

Phone:

612-262-5980

 

Fax:

612-262-5988

 

For a list of Allina Health locations and addresses, please visit allinahealth.org

 

SR-10290 11/2019

allinahealth.org/medicalrecords

 

 

 

 

How to Edit Allina Hospitals And Clinics Form Online for Free

Using FormsPal's free PDF editor, you can complete the Allina Hospitals and Clinics authorization form entirely online without downloading special software. Follow the steps below to fill out, sign, and save your completed Allina health release of information form.

Step 1: Click the "Get Form" button at the top of this page to open the Allina authorization form in FormsPal's secure online editor.

Step 2: Begin entering your patient information in the first section of the form. Fill in your personal and contact details accurately:

Filling in patient information on the Allina health release of information form

Step 3: Complete the authorization details. Specify whether you want records transferred from or to Allina Health, select the purpose of release, and indicate the type of records needed. Fields include INFORMATION TO BE RELEASED, What Information do you want, I want my records for dates of, Billing Records, Community Pharmacy Pathology, Clinic Record Set office visit, Individual Report Options, Discharge Summary/Note History, Clinic/Progress Notes, Laboratory Reports/Pathology, Immunization Record/Allergy Record, Any and All Records, Special Disclosure Permissions, Chemical Dependency/Substance Use, and Mental Health Records/HIV Test:

Completing authorization details on the Allina health release of information form

Step 4: In the final section, review and complete the authorization duration and signature fields: This authorization lasts for one (year), Patient/Legal Guardian Signature, Date, and Authority to act on behalf of. Take care with the Authority to act field and review it before finalizing:

Signing the Allina authorization to release information form

Step 5: Review all entries for accuracy. When complete, click "Done" to save or download your completed Allina authorization form as a PDF. FormsPal does not share or sell any personal information you enter.

Frequently Asked Questions About the Allina Authorization Form

How long is the Allina authorization form valid?

The Allina health release of information authorization is valid for one year from the date of signing unless you specify a shorter period or revoke it beforehand. You may revoke the authorization at any time by contacting Allina Health medical records.

What records can I request using this form?

You can request any health records in Allina Health's possession, including clinic and hospital visits, billing records, radiology images, laboratory results, immunization records, discharge summaries, and specialized records such as mental health or substance use records. Minnesota law requires separate authorization for certain sensitive record categories.

Who can sign the Allina health authorization form?

The patient must sign if they are 18 or older. For minors, a parent or legal guardian may sign. If the patient is deceased or incapacitated, a personal representative, legal guardian, or power of attorney holder may authorize release on the patient's behalf.

Are there similar forms for other healthcare providers?

Yes. FormsPal also provides the United Healthcare release of information form, the Kaiser Permanente health information form, and the Hoag medical records request for other healthcare providers.

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