Authorization to Release Health Information

Authorization to Release Health Information

I, (name of patient/personal representative), hereby authorize the release of personal health information to Minnesota Hospice regarding the following patient.

Patient Information

This section of the form requests the patient's name and address, date of birth, and patient's phone number.

Disclosing Agency

This section of the form requests the disclosing agency's name, address, phone, and fax number.

Information to Be Provided To

Minnesota Hospice, 17645 Juniper Path, Suite 155, Lakeville, MN 55044. Phone: 952-898-1022. Fax: 952-898-4006.

Purpose of Disclosure

The purpose or need for this disclosure is Hospice. Please include 6 months of information for the items checked below.

• Discharge summary
• Lab results
• History and physical exam
• Consultation reports
• HIV/AIDS test results and treatment if applicable
• Alcohol/drug abuse treatment/referral if applicable
• Progress notes
• Photographs, videotapes, or other images
• Mental health - other than psychotherapy notes
• X-Ray reports
• Summary of treatment
• Other (specify)

Terms of Authorization

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If this authorization has not been revoked, it will terminate one year from the date of signature unless a different expiration date is specified.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.

If the purpose is for marketing, the company will not receive direct or indirect compensation or payment in return for using or disclosing the patient's health information.

Signatures

This form requires a signature and date from the patient or authorized representative, and a signature and date from a Minnesota Hospice representative.