This form was approved by the Commissioner of the Minnesota Department of Health on January 30, 2008 and updated in Feb. 2024 Feb. 2024
Instrucons for Minnesota Standard Consent
Form to Release Health Informaon
Important: Please read all instrucons and informaon before compleng and signing the form.
An incomplete form might not be accepted. Please follow the direcons carefully. If you have any quesons about the release of
your health informaon or this form, please contact the organizaon you will list in secon 3.
This standard form was developed by the Minnesota Department of Health as required by the Minnesota Health Records Act
of 2007, Minnesota Statutes, secon 144.292, subdivision 8. The form must be accepted by a Minnesota provider as a legally
enforceable request under the Minnesota Health Records Act. If completed properly, this form must be accepted by the health
care organizaon(s), specic health care facility(ies), or specic professional(s) idened in secon 3.
A fee may be charged for the release of the health informaon.
The following are instrucons for each secon. Please type or print as clearly and completely as possible.
1
Include your full and complete name. If you have a sux
aer your last name (Sr., Jr., III), please provide it in the “last
name” blank with your last name. If you used a previous
name(s), please include that informaon. If you know your
medical record or paent idencaon number, please
include that informaon. All these items are used to idenfy
your health informaon and to make certain that only your
informaon is sent.
2
If there are quesons about how this form was lled out, this
secon gives the organizaon that will provide the health
informaon permission to speak to the person listed in this
secon. Compleng this secon is oponal.
3
In this secon, state who is sending your health informaon.
Please be as specic as possible. If you want to limit what
is sent, you can name a specic facility, for example Main
Street Clinic. Or name a specic professional, for example
chiropractor John Jones. Please use the specic lines.
Providing locaon informaon may help make your request
more clear. Please print “All my health care providers” in this
secon if you want health informaon from all of your health
care providers to be released.
4
Indicate where you would like the requested health
informaon sent. It is best to provide a complete mailing
address as not everyone will fax health informaon. A place
has been provided to indicate a deadline for providing the
health informaon. Providing a date is oponal.
5
5 Indicate what health informaon you want sent. If you want
to limit the health informaon that is sent to a parcular
date(s) or year(s), indicate that on the line provided.
For your protecon, it is recommended that you inial
instead of check the requested categories of health
informaon. This helps prevent others from changing your
form.
EXAMPLE: All health informaon
If you select all health informaon, this will include any
informaon about you related to mental health evaluaon
and treatment, concerns about drug and/or alcohol use, HIV/
AIDS tesng and treatment, sexually transmied diseases and
genec informaon.
Important: There are certain types of health informaon that
require special consent by law.
Chemical dependency program informaon comes from
a program or provider that specically assesses and treats
alcohol or drug addicons and receives federal funding. This
type of health informaon is dierent from notes about a
conversaon with your physician or therapist about alcohol
or drug use. To have this type of health informaon sent,
mark or inial on the line at the boom of page 1.
Psychotherapy notes are kept by your psychiatrist,
psychologist or other mental health professional in a
separate ling system in their oce and not with your
other health informaon. For the release of psychotherapy
notes, you must complete a separate form nong only that
category. You must also name the professional who will
release the psychotherapy notes in secon 3.
6
Health informaon includes both wrien and oral
informaon. If you do not want to give permission for
persons in secon 3 to talk with persons in secon 4 about
your health informaon, you need to indicate that in this
secon.
7
Please indicate the reason for releasing the health
informaon. If you indicate markeng, please contact
the organizaon in secon 4 to determine if payment or
compensaon is involved. If payment or compensaon to the
organizaon is involved, indicate the amount.
8
This consent will expire one year from the date of your
signature, unless you indicate a dierent date or event.
Examples of an event are: “60 days aer I leave the hospital,”
or “once the health informaon is sent.”
9
Please sign and date this form. If you are a legally authorized
representave of the paent, please sign, date and indicate
your relaonship to the paent. You may be asked to provide
documents showing that you are the paent or the paent’s
legally authorized representave.
This form was approved by the Commissioner of the Minnesota Department of Health on January 30, 2008 and updated in August 2015 Feb. 2024
Minnesota Standard Consent Form to Release Health Informaon
PAGE 1 OF 2
1.
First name Middle name Last name
Paent Informaon
Paent date of birth Previous name(s)
MM DD YYYY
Home address
City State
Zip code
Dayme phone Email address (oponal)
Medical Record/paent ID number (oponal)
2.
Contact for informaon about how this form was lled out (oponal)
First name
I give permission for the organizaon(s) listed in secon 3 permission to talk to
Last name about how this form was completed.
This person can be reached at: Dayme phone Email address (oponal)
3.
I am requesng health informaon be released from at least one of the following:
Organizaon(s) name
Specic health care facility or locaon(s)
Specic health care professional’s name(s)
4.
I am requesng that health informaon be sent to:
Organizaon(s) name
First name Last nameAnd/or person:
Mailing address
City State Zip code
Phone (oponal) Fax (oponal)
Informaon needed by (date)
MM DD YYYY
(oponal)
5.
Informaon to be released
IMPORTANT: indicate only the informaon that you are authorizing to be released.
Specic dates/years of treatment
All health informaon (see descripon in instrucons for what is included)
OR to only release specic porons of your health informaon, indicate the categories to be released:
History/Physical
Laboratory report
Emergency room report
Surgical report
Medicaons
Other informaon or instrucons
Mental health
Discharge summary
Progress notes
Care plan
Immunizaons
HIV/AIDS tesng
Radiology report
Radiology image(s)
Photographs, video, digital or other images
Billing records
The following informaon requires special consent by law. Even if you indicate all health informaon, you must
specically request the following informaon in order for it to be released:
Chemical dependency program (see denion in instrucons)
Psychotherapy notes (this consent cannot be combined with any other; see instrucons)
This form was approved by the Commissioner of the Minnesota Department of Health on January 30, 2008 and updated in Feb. 2024 Feb. 2024
Minnesota Standard Consent Form to Release Health Informaon
PAGE 2 OF 2
6.
Health informaon includes wrien and oral informaon
By indicang any of the categories in secon 5, you are giving permission for wrien informaon to be released and for a
person in secon 3 to talk to a person in secon 4 about your health informaon.
If you do not want to give your permission for a person in secon 3 to talk to a person in secon 4 about your health
informaon, indicate that here (check mark or inials)
7.
Reasons for releasing informaon
Insurance applicaon
Legal
Appeal denial of Social Security Disability income or benets
Markeng purposes (payment or compensaon involved?
Sale (payment or compensaon to enty maintaining the informaon?
Other (please explain)
Paent’s request
Review paent’s current care
Treatment/connued care
Payment
NO YES, amount )
NO YES)
8.
I understand that by signing this form, I am requesng that the health informaon specied in Secon 5 be sent to the
third party named in secon 4.
I may stop this consent at any me by wring to the organizaon(s), facility(ies) and/or professional(s) named in secon 3.
If the organizaon, facility or professional named in secon 3 has already released health informaon based on my
consent, my request to stop will not work for that health informaon.
I understand that when the health informaon specied in secon 5 is sent to the third party named in secon 4, the
informaon could be re-disclosed by the third party that receives it and may no longer be protected by federal or state
privacy laws.
I understand that if the organizaon named in secon 4 is a health care provider they will not condion treatment,
payment, enrollment or eligibility for benets on whether I sign the consent form.
If I choose not to sign this form and the organizaon named in secon 4 is an insurance company, my failure to sign will
not impact my treatment; I may not be able to get new or dierent insurance; and/or I may not be able to get insurance
payment for my care.
This consent will end one year from the date the form is signed unless I indicate an earlier date or event here:
Date
MM DD YYYY
Or specic event
9.
Paent’s signature
Date
MM DD YYYY
OR legally authorized representave’s signature
Date
MM DD YYYY
Representave’s relaonship to paent (parent, guardian, etc.)
The Genec Informaon Nondiscriminaon Act of 2008 (GINA) prohibits employers and other
enes covered by GINA Title II from requesng genec informaon of any individual or
family member of the individual, except as specically allowed by this law.
