Authorization to Release Medical Information Please enable JavaScript in your browser to complete this form.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 # Signed FAX # Clinic AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeProvider Name *Clinic Phone *Clinic FAXSend my records TO: OB/GYN Specialists Attn: Medical Records 6565 France Avenue S Suite 200Edina, MN 55435 Phone: 952-435-4190FAX: 952-892-3372Email: Info@obgynpa.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
