Allina Hospitals And Clinics Form – Fill Out and Use This PDF

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 *

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