Bluestone Physician Services
Attn: Medical Records Department
270 Main Street N, Suite 300
Stillwater, MN 55082
Fax: 855-490-4045 Phone: 651-342-4275
This authorization is intended to provide my health care providers with the written authorization necessary to allow each of them to disclosemy individually identifiable health information regarding my health or medical records to Bluestone Physician Services. I hereby release myexpectation of privacy in such situations and agree to hold harmless any covered entity that acts in reliance on this authorization
I hereby authorize the release of my individually identifiable health information described above for treatment and payment purposes. I understand that this authorization to release health information is voluntary. I understand that the information disclosed under this authorization may be redisclosed by the recipient and may no longer be protected by federal or state law.
I understand that my healthcare and the payment for my healthcare will not be affected by my signing of this form. I understand I may request a copy of this form after I sign it. I understand that this authorization may be revoked by me by written notice to Bluestone Physician Services. I understand that if I revoke this authorization it will not have any effect on any actions taken by Bluestone Physician Services before receiving my revocation. This release covers past, present and future encounters/visits unless I write in specific treatment dates here: Date to Date . This consent will expire one year from the date it is signed unless I indicate a specific date here Date .
I acknowledge and agree that by signing this form as a Legal Representative for the patient, I swear and attest that I am legally authorized to act and make decisions on behalf of the patient. I am required to provide a copy of valid and effective documentation outlining my role as Legal Representative in order to receive related communications. Upon signing the form or any other required documentation from Bluestone as a Legal Representative for the patient, I hereby release and hold harmless Bluestone Physician Services and its representatives from any claims or damages arising from Bluestone’s reliance on my attestation that I am Legal Representative.