Rum River Counseling Release of Info

Authorization for Release of Protected Health Information
Client Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date today

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
age
Date Range of Requested Information:
Date From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date To

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If all dates (check here)
This authorization expires (ends) on the following date: (If a date is not specified, this authorization expires twelve (12) months from the date I sign this form.)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Release (How do you want the information shared?)
Health Information Release (you may select more than one option):
Name of Person, Provider, Hospital, etc. that information can be shared with.
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Purpose of Release

Other
Type of Medical Information to be disclosed

Other
Other Information allowed to be disclosed
I understand that I may revoke this authorization at any time by notifying Rum River Counseling, Inc. in writing. Revoking this authorization does not apply to information that has already been released under this authorization. I have the right to inspect or copy the health information to be disclosed. Information that goes to a health care provider or health plan covered by federal privacy laws will be protected by federal privacy laws. Rum River Counseling, Inc. cannot re-disclose any information from other persons or entities as protected by state or federal privacy laws. I do not have to sign this form. Treatment will still be provided to me if I do not sign this form. Payment for services is not contingent upon me signing this form, unless those services are for the sole purpose of creating personal information for a third party, such as insurance companies. A fee may be charged for retrieval and copying of records according to MN 144.335 and Federal Rule 164.521.

Signature of Client or Client's Legal Representative
Full name of person signing this form

First NameLast Name
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Parent or Legally Authorized Representative

In case the client is below the legal age of consent:
Name of Parent or Guardian

First NameLast Name
Relationship to Client
Signature of Parent / Guardian
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: