Authorization for Release of Medical Information Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastPrevious Name (s)FirstMiddleLastPatient Date of Birth: *Send my records FROM: *If you are requesting records from Mayo to be sent to our clinic we will need your Mayo MRN number in order for them to process.Mayo MRN #Clinic AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeProvider Name *Clinic Phone *Clinic FAX this typed authorization Send my records TO: OB/GYN & Infertility Attn: Medical Records 6405 France Avenue Suite W400Edina, MN 55435 Phone: 952-920-2730FAX: 952-567-7090Email: Info@obgynmn.comTypes of Records *All Health Information (not including billing)Other:If you chose Other, what other records do you want sent? Reason For Request *Personal UseDisabilityInsuranceLegalWorkers CompensationContinuing Care(please record the purpose of the disclosure or check patient request)I Understand That By Signing The Below: – I may revoke this authorization at any time by notifying i-Health in writing. If I revoke this authorization, i-Health will no longer use or disclose my health information for the reasons covered by this authorization, except to the extent it has already relied upon this authorization. – By authorizing the release of my protected health information, the health information may no longer be protected and has the potential to be re-disclosed. – There may be a fee for release of this information and I may be responsible for that fee. – I am authorizing the release of my personal protected health information from any i-Health facility, unless otherwise specified above. – Treatment will not be denied to me if I do not sign this form. – If I provided an email address in section 3, I understand that the requested records will be sent via encrypted email, or it may be sent to a patient portal. – i-Health is a multispecialty practice including, and without limitation, the clinic above. Your i-Health record will be released, unless you otherwise specify in writing Signed By: PatientPatient RepresentativeThis authorization will expire one year from the date I sign this form, unless specified: Signature (It is agreed a typed name is considered a signature)DateSubmit
