Authorization for Release of Health Information

Authorization for Release of Health Information
Patient Information
Please use full legal name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Community*
Room #*
Release Information (Required):*

ToFrom
Clinic Name or Individual's Name*

Clinic Name

Street Address

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid Fax number.
Release Information (Required):*

ToFrom
Bluestone Physician Services

Attn: Medical Records Department

270 Main Street N, Suite 300

Stillwater, MN 55082

Fax: 855-490-4045 Phone: 651-342-4275
Information to Be Released (Required)

Indicate ONLY the information that you are authorizing to be released
Notes from four most recent provider visitsLabs and imaging within the last two yearsHospital discharges within the last two yearsOthersAll records
By law, you must specifically request the following information for it to be released:
Chemical dependency Program:*

YesNo
Psychotherapy notes:*

YesNo
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 .
Patient or Legal Representative Signature*

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Date*

MonthDayYear
Date
Signature Verification*

I verify that I have electronically signed above and that my signature is displayed in the signature box.
Legal Representative Printed Name and Authority to sign for patient (i.e. Health Care Directive, Medical POA; must include documentation)

First NameLast Name
Should be Empty:

Authorization for Release of Health Information

Patient Information

Information to Be Released (Required)

By law, you must specifically request the following information for it to be released: