The form should be faxed to Minnesota Hospice at 952.898.4006 or emailed to info@mnhospice.com.
This form authorizes Minnesota Hospice to receive a patient’s health information from another provider or agency. You can access this form in two formats below.
View the accessible HTML version below (this works well with screen readers and keyboard navigation)
Click to download the printable PDF version (270 KB, use this version if you need to print and fill it out by hand)
The patient or authorized representative authorizes the release of personal health information to Minnesota Hospice regarding the patient. This section provides a field for the name of the patient or authorized representative.
This section provides fields for the patient's name and address, date of birth, and patient's phone number.
This section provides fields for the disclosing agency's name, address, phone, and fax number.
Minnesota Hospice, 17645 Juniper Path, Suite 155, Lakeville, MN 55044. Phone: 952-898-1022. Fax: 952-898-4006.
The purpose or need for this disclosure is Hospice. The form requests that six months of information be included for the items checked below:
I understand that I may revoke this authorization in writing submitted at any time to the company, except to the extent that action has already been taken on this authorization or this authorization was obtained as a condition of obtaining insurance coverage or a policy, in which case other law may provide the insurer with the right to contest a claim under the policy.
If this authorization has not been revoked, it will terminate one year from the date of signature unless a different expiration date is specified.
The company will not condition treatment or eligibility for care on providing this authorization, except if such care is research related.
Information disclosed by this authorization, except for Alcohol and Drug Abuse as defined in 42 CFR Part 2, may be subject to re-disclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy Rule (45 CFR Part 164) and the Privacy Act of 1974 (5 USC 552a).
This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose.
The form asks whether, if the purpose is for marketing, the company will receive direct or indirect compensation or payment in return for using or disclosing the patient's health information, with yes and no options.
This form requires a signature and date from the patient or authorized representative, and a signature and date from a Minnesota Hospice representative.
Download the printable Authorization to Release Health Information form (PDF, 270 KB)