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- 1 - AU TH ORIZ A TIO N T O R ELE A SE T R EA TM EN TREC O RD S, R EPO RTS, A ND I N FO RM ATIO N __ _____ ____________ _ _____ ____________ _ _____ ___________T ele p ho ne: _ _ ____________ ____ R e: __________ ___________ D OB _ _____ _______________S S# _ ____ ________________ T his i s f u ll a n d s u ffic ie n t a u th oriz atio n p urs u an t t o M in neso ta S ta tu te s S ectio n 1 14.3 35 t o rele ase t o _ ______________ ______ o f t h e l a w f ir m o f _ ____________________, __ _____ ______________ , _ ____________________, _ ____________________, __ _____ ______________ , o r t h eir e m plo yees o r a g en ts a ll i n fo rm atio n t h ey m ay r e q uest, w ritte n o r ve rb al, p erta in in g t o a n y a n d a ll c o nsu lta tio n, t r e atm en t, a n d c o unse lin g r e n dere d t o m e. Y ou m ay als o a llo w t h e a fo re m en tio n ed o r a n yone a p poin te d b y t h em t o e x am in e a n y r e co rd s, c h arts , r e p orts , no te s, o r o th er r e co rd ed i n fo rm atio n r e g ard in g a n y c o nsu lta tio n, t r e atm en t, a n d c o unse lin g r e n dere d to m e b y y ou w hile . T he r e co rd s, r e p orts , a n d i n fo rm atio n a re n eed ed f o r u se i n c o nnectio n w ith m y pen din g m arria g e d is so lu tio n a ctio n.I u nders ta n d t h at I m ay r e v oke t h is c o nse n t a t a n ytim e a n d t h at u pon f u lf illm en t o f t h e ab ove-s ta te d p u rp ose , t h is c o nse n t w ill a u to m atic ally e x p ir e w ith out m y e x pre ss r e v ocatio n.H IP A A R ele ase A uth ority . M y a g en t s h all b e t r e ate d a s I w ould b e w ith r e sp ect t o m y r ig hts re g ard in g th e u se a n d d is c lo su re o f m y in div id ually id en tif ia b le h ealth in fo rm atio n o r o th er m ed ic al re co rd s. T his re le ase au th ority ap plie s to an y in fo rm atio n govern ed by th e H ealth In su ra n ce Po rta b ility a n d A cco unta b il ity A ct o f 1 996 (H IP A A), 4 2 U .S .C . 1 320d a n d 4 5 C FR 1 60 th ro ugh 16 4. I au th oriz e an y physic ia n , health care pro fe ssio nal, den tis t, health pla n , hosp ita l, clin ic , la b ora to ry , p harm acy , o r o th er co vere d h ealth care p ro vid er, an y in su ra n ce co m pan y, an d th e Me d ic al I n fo rm atio n B ure a u , I n c. o r o th er h ealth c are c le arin ghouse th at h as p ro vid ed tr e atm en t o r se rv ic es to m e, o r th at h as p aid fo r o r is se ek in g p ay m en t fro m m e fo r su ch se rv ic es, to g iv e, di s c lo se an d re le ase to m y ag en t, w ith out re str ic tio n, all o f m y in div id ually id en tif ia b le h ealth in fo rm atio n a n d m ed ic al re co rd s re g ard in g a n y p ast, p re se n t o r fu tu re m ed ic al o r m en ta l h ealth co nditio n, in clu din g a ll in fo rm atio n re la tin g to th e d ia g nosis o f H IV /A ID S, se x ually tr a n sm itte d dis e ase s, m en ta l illn ess, a n d d ru g o r a lc o hol a b use . T he a u th ority g iv en m y a g en t s h all s u pers e d e an y o th er a g re em en t th at I m ay h av e m ad e w ith m y h ealth c are p ro vid ers to re str ic t a ccess to o r dis c lo su re o f m y i n div id ually i d en tif ia b le h ealth i n fo rm atio n. D ate d : _ ______ __________ _ _______________________________ C lie n t - 2 - I v erif y t h at t h e p ro ceed in g i n w hic h t h is i n fo rm atio n i s r e q uir e d i s s till p en din g a n d t h at in fo rm atio n p ro vid ed p urs u an t t o t h is a u th oriz atio n w ill n ot b e r e -re le ase d f o r p urp ose s n ot r e la te d to t h is p ro ceed in g. D ate d : _ ______ __________ _ _______________________________ _____________________ A tto rn ey f o r P etitio ner A TTEN TIO N P U BLIC F A CIL IT IE S: M in neso ta S ta tu te s S ectio n 1 3.0 5, s u bd. 4 , r e q uir e s au to m atic e x pir a tio n o f t h is a u th oriz atio n o ne y ear f ro m t h e d ate o f t h is a u th oriz atio n. - 3 - AUTH ORIZ A TIO N NAM E: __________ ___________ __________ ___________ T IT LE:_ ________________ _ M an ag er A DDRESS: __________ ________ __________ __________________ ________T ele p hone: _ _ ________________ R E: _________________ _ _________________ __________________ _ T O W HOM I T M AY C O NCER N : YOU A RE H ER EB Y A UTH ORIZ ED t o g iv e t h e l a w f ir m o f _ ____________________, __ _____ ______________ , _ ____________________, M in neso ta _ ____________________, a n d an y o f t h e a tto rn ey s, l e g al a ssis ta n ts , o r a g en ts e m plo yed b y t h at f ir m , a n y a n d a ll i n fo rm atio n t h at yo u h av e p erta in in g t o m y p artic ip atio n i n t h e _ ______ ______________ P la n a n y a n d a ll b en efits t o whic h I a m o r m ay b e e n titl e d a s a p artic ip an t i n t h at f u nd, i n clu din g b ut n ot l im ite d t o t h e fo llo w in g:1. Am ount o f c o ntr ib utio ns I h av e m ad e t o d ate ,2 . The n um ber o f y ears , m onth s, a n d d ay s o f p artic ip atio n,3. Date o f v esti n g,4. The a ccru ed v este d m onth ly b en efit,5 . The c u rre n t b ala n ce i n t h e a cco unt,6 . The e stim ate d m onth ly b en efit u pon r e tir e m en t,7 . The a m ount o f i n te re st t h at h as a ccru ed o n t h e a cco unt,8 . The a m ount o f a n y e m plo yer c o ntr ib utio n t o t h e a cco unt.Y ou a re f u rth er a u th oriz ed t o a llo w s a id p ers o n s t o e x am in e a n d c o py a n y a n d a ll d ocu m en ts co nta in in g s u ch i n fo rm atio n a n d t o d eliv er c o pie s o f a n y a n d a ll p ertin en t d ocu m en ts t o s a id l a w fir m . T his a u th oriz atio n w ill a u to m atic ally e x pir e a t t h e e n d o f o ne y ear u nle ss e x pre ssly r e v oked by m e i n w ritin g b efo re t h at t im e. D ate d : _ ______ __________ _ __________________________ _____________________ - 4 - PA TIE N T A UTH ORIZ A TIO N FO R R ELEA SE O F I N FO RM ATIO N TO : _________________ _ (F or u se b y l a w yers a nd l a w o ffic es) _ ________________ _ _ _____ ___________ _R E: _ __ _______________ ( P atie n t's n am e) _ _ ________________ ( D ate o f b ir th a n d/o r S oc. S ec. # ) T his i s y our f u ll a n d s u ffic ie n t a u th oriz atio n, p urs u an t t o M in n. S ta t. S ectio n 1 44.3 35, t o rele ase t o : _ __ ___________ ____ t h eir r e p re se n ta tiv es o r e m plo yees, a ll m ed ic al i n fo rm atio n (in clu din g b ut n ot l im ite d t o t h at w hic h i n volv es t r e atm en t f o r a lc o hol o r d ru g a b use , s ic k le c ell an em ia , o r m en ta l p ro ble m s) m ain ta in ed w hile I w as a p atie n t a t y our f a cility o n a n y d ate , w ith t h e fo llo w in g e x cep tio ns: _ ____ ________________ __ _____ ______________ . T his i n fo rm atio n i s n eed ed f o r t h e p urp ose o f: _ ____________________.T his a u th oriz atio n s p ecif ic ally i n clu des r e co rd s p re p are d p rio r t o t h e d ate o f t h is au th oriz atio n a n d r e co rd s p re p are d a fte r t h e d ate o f t h is a u th oriz atio n d urin g t h e p en den cy o f t h is pro ceed in g ( in clu din g c la im s a n d p ote n tia l c la im s). I d o n ot a u th oriz e r e -re le ase o f t h is i n fo rm atio n by t h e t h ir d p arty .I u nders ta n d t h at I m ay r e v oke t h is c o nse n t i n w ritin g a t a n y t im e, b ut t h at s u ch r e v ocatio n may a d vers e ly a ffe ct t h e c o urs e o f t h e p ro ceed in g r e q uir in g t h ese r e co rd s. U pon t h e f u lf illm en t o f th e a b ove s ta te d p urp ose , t h is c o nse n t w ill a u to m atic ally e x pir e w ith out m y e x pre ss r e v ocatio n. A photo co py o f t h is a u th oriz atio n w ill b e t r e ate d i n t h e s a m e m an ner a s a n o rig in al. C onvers a tio ns b y the b eare r o f t h is a u th oriz ati o n w ith p hysic ia n s, h ow ev er, a re /a re n ot ( s tr ik e o ne) a u th oriz ed b y t h is re le ase f o rm . _________________________ ______S ig natu re o f P atie n t/G uard ia n Date _ _________________________________________ R ela tio nsh ip t o P atie n t__________________________________________R easo n P atie n t u n ab le t o s ig n - 5 - I v erif y th at th e p ro ceed in g re q uir in g th is in fo rm atio n is s till p en din g a n d th at in fo rm atio n pro vid ed p urs u an t to th is au th oriz atio n w ill n ot b e re -re le ase d fo r p urp ose s n ot re la te d to th is pro ceed in g. _ _________________________ _ _____S ig natu re o f p arty r e q uestin g D atein fo rm atio n A TTEN TIO N P U BLIC F A CIL IT IE S: M in neso ta S ta tu te s S ectio n 15.1 63 re q uir e s au to m atic ex pir a tio n o f t h is a u th oriz atio n o ne y ear f ro m d ate o f a u th oriz atio n.F orm a ppro ve d b y M in neso ta S ta te M ed ic a l A sso cia tio n, M in neso ta S ta te H osp ita l A sso cia tio n, Mi n neso ta S ta te B ar A sso cia tio n, a nd M in neso ta A sso cia tio n o f H osp ita l A tto rn eys. - 6 - AUTH ORIZ A TIO N T O R ELEA SE F IN ANCIA L R EC O RD S, R EPO RTS A ND I N FO RM ATIO N TO : _ _________________ (F or u se b y l a w yers a nd l a w o ffic es) _ _________________ _ _________________R E: _ __ _______________ ( P atie n t's n am e) _ _ ________________ I d o h ere b y a u th oriz e t h e a b ove-n am ed t o r e le ase t o _ ____________________, t h eir em plo yees, a g en ts , o r r e p re se n ta tiv es, a n y a n d a ll b an kin g r e co rd s, a s m ay b e r e q ueste d b y t h em i n connectio n w it h m y p en din g a ctio n f o r d is so lu tio n o f m arria g e.T his a u th oriz atio n w ill a u to m atic ally e x pir e o ne y ear f ro m t h e d ate o f t h e a u th oriz atio n unle ss e arlie r r e v oked b y m e. D ate : _ _ ________________ ________________________________ I v erif y t h at t h e p ro ceed in g i n w hic h t h is i n fo rm atio n i s r e q uir e d i s s till p en din g a n d t h at in fo rm atio n p ro vid ed p urs u an t t o t h is a u th oriz atio n w ill n ot r e -re le ase d f o r p urp ose s n ot r e la te d t o this p ro ceed in g. D ate d : _ ______ __________ _ ________________________________ - 7 - AUTH ORIZ A TIO N TO : _ _________________ (F or u se b y l a w yers a nd l a w o ffic es) _ _________________ _ _________________R E: _ __ _______________ ( P atie n t's n am e) _ _ ________________ I h ere b y a u th oriz e t h e _ ______________ ___ o r i ts a g en ts t o r e le ase t h e i n fo rm atio n sp ecif ie d b elo w c o ncern in g _ _________________ t o _ _________________, A tto rn ey a t L aw , __ _____ ___________ , M in neso ta , _ ________________ ____: A c o py o f t h is a u th oriz atio n s h all b e e q uiv ale n t t o t h e o rig in al. D ate d : _ ______ __________ _ ______________________________ I v erif y th at th e p ro ceed in g in w hic h th is in fo rm atio n is r e q uir e d is s till p en din g a n d th at in fo rm atio n p ro vid ed p urs u an t t o t h is a u th oriz atio n w ill n ot r e -re le ase d f o r p urp ose s n ot r e la te d t o this p ro ceed in g. D ate d : _ _______________ __ ___________________ _________________________________ - 8 - AUTH ORIZ A TIO N T O R ELEA SE M ED IC A L A ND/O R R EC O RD S, R EPO RTS, A ND I N FO RM ATIO N TO : _ _________________ (F or u se b y l a w yers a nd l a w o ffic es) _ _________________ _ _________________R E: _ __ _______________ ( P atie n t's n am e) _ _ ________________ T his i s f u ll a n d s u ffic ie n t a u th oriz atio n p urs u an t t o M in neso ta S ta tu te s S ectio n 1 14.3 35 t o rele ase t o _ ______________ ______, a n d a n y a n d a ll a tto rn ey s, l e g al a ssis ta n ts , a n d a g en ts t h ere o f, al l i n fo rm atio n t h ey m ay r e q uest, w ritte n o r v erb al, p erta in in g t o a n y a n d a ll c o nsu lta tio n, t r e atm en t, an d c o unse lin g r e n dere d w hile I w as a p atie n t o r c lie n t. Y ou m ay a ls o a llo w t h e a fo re m en tio ned o r an yone a p poin te d b y t h em t o e x am in e a n y r e co rd s, c h arts , r e p orts , X -ra y s, o r o th er r e co rd ed info rm atio n r e g ard in g a n y c o nsu lta tio n, t r e atm en t, a n d c o unse lin g r e n dere d b y y ou w hile I w as a pa tie n t o r c lie n t. T he r e co rd s, r e p orts , a n d i n fo rm atio n a re n eed ed f o r u se i n c o nnectio n w ith m y pen din g m arria g e d is so lu tio n a ctio n. I u nders ta n d t h at I m ay r e v oke t h is c o nse n t a t a n y t im e a n d t h at u pon f u lf illm en t o f t h e a b ove- sta te d p urp ose , t h is c o nse n t w ill a u to m atic ally e x pir e w ith out m y e x pre ss r e v ocatio n. D ate d : _ ___ ______________ __ ________________________________ P atie n t C lie n t I v erif y t h at t h e p ro ceed in g i n w hic h t h is i n fo rm atio n i s r e q uir e d i s s till p en din g a n d th at i n fo rm atio n p ro vid ed p u rs u an t t o t h is a u th oriz atio n w ill n ot b e r e -re le ase d f o r p urp ose s n ot re la te d t o t h is p ro ceed in g.D ate d : _ ___ ______________ _____ ______________________________ A tto rn ey A TTEN TIO N PU BLIC FA CIL IT IE S: Min neso ta Sta tu te s Sectio n 13.0 5, su bd. 4, re q uir e s au to m atic e x pir a tio n o f t h is a u th oriz atio n o ne y ear f ro m t h e d ate o f t h e a u th oriz atio n. - 9 - AUTH ORIZ A TIO N T O R ELEA SE F IN ANCIA L R EC O RD S, R EPO RTS A ND I N FO RM ATIO N TO : _ _________________ (F or u se b y l a w yers a n d l a w o ffic es) _ _________________ _ _________________R E: _ __ _______________ ( P atie n t's n am e) _ _ ________________ I , _ ______ ____________ __, d o h ere b y a u th oriz e t h e a b ove-n am ed a cco unta n ts t o r e le ase t o m y atto rn ey , _ _______________ _____, t h eir e m plo yees, a g en ts , o r r e p re se n ta tiv es, a n d t o t h e ac co untin g f ir m o f _ ______ ______________, t h eir e m plo yees, a g en ts , o r r e p re se n ta tiv es, a n y a n d all f in an cia l r e c o rd s, t a x r e tu rn s, r e p orts a n d i n fo rm atio n p erta in in g t o _ ____________________ a s ma y b e r e q ueste d b y t h em f o r t h e p urp ose o f v alu in g t h e f ir m a n d m y i n te re st t h ere in i n c o nnectio n with m y p en din g a ctio n f o r d is so lu tio n o f m arria g e.D ate : _ _ ________________ ________________________________ Willia m J . S ch m id t I v erif y t h at t h e p ro ceed in g i n w hic h t h is i n fo rm atio n i s r e q uir e d i s s till p en din g a n d t h at in fo rm atio n p ro vid ed p urs u an t t o t h is a u th oriz atio n w ill n ot b e r e -re le ase d f o r p urp ose s n ot r e la te d t o this p ro ceed in g.D ate d : _ ______ __________ _ ___________________________________ _ ____________________________A tto rn ey f o r _ ____________________ - 10 - A UTH O RIZ A TIO N T O R ELEA SE P R IV IL EG ED R EC O RD S, R EPO RTS A ND I N FO RM ATIO N TO : _ _________________ (F or u se b y l a w yers a nd l a w o ffic es) _ _________________ _ _________________R E: _ __ _______________ ( P atie n t's n am e) I , _ ______ ____________ __, d o h ere b y a u th oriz e t h e a b ove-n am ed a tto rn ey t o r e le ase t o m y p re se n t at to rn ey , _ _______________ _____th eir e m plo yees, a g en ts , o r r e p re se n ta tiv es a n y a n d a ll f ile s, pl e ad in gs, d ocu m en ts , r e co rd s, r e p orts a n d i n fo rm atio n p erta in in g t o a n y c rim in al p ro ceed in gs b ro ught ag ain st m e. I f u rth er a u th oriz e t h e a b ove-n am ed a tto rn ey t o c o nfe r w ith a n d d is c lo se t o _______ ______________ , t h eir e m plo yees, a g en ts , o r r e p re se n ta tiv es a n y i n fo rm atio n w heth er o r n ot su bje ct t o t h e c lie n t- a tto rn ey p riv ile g e, a s m ay b e r e q ueste d b y t h em .Date : _ _ ________________ _ ______________________________ I v erif y t h at t h e p ro ceed in g i n w hic h t h is i n fo rm atio n i s r e q uir e d i s s till p en din g a n d t h at in fo rm atio n p ro vid ed p urs u an t t o t h is a u th oriz atio n w ill n ot b e r e -re le ase d f o r p urp ose s n ot r e la te d t o this p ro ceed in g.D ate d : _ ______ __________ _ ____________________________________ - 11 - A UTH O RIZ A TIO N T O R ELEA SE F IN ANCIA L R EC O RD S, R EPO RTS A ND I N FO RM ATIO N T O : _ _________________ (F or u se b y l a w yers a nd l a w o ffic es) _ _________________ _ _________________R E: _ __ _______________ (P atie n t's n am e) _ _ ________________ I, _ ____ __________ ______, d o h ere b y a u th oriz e t h e a b ove-n am ed t o r e le ase t o t h e a tto rn ey , __ _____ ______________ , t h eir e m plo yees, a g en ts , o r r e p re se n ta tiv es, a n y a n d a ll f in an cia l s ta te m en ts , st a te m en ts o f a cco unt, f in an cia l r e co rd s, r e p orts a n d a n y o th er f in an cia l i n fo rm atio n p erta in in g t o _______ ______________ a n d _ ____________________ a s m ay b e r e q ueste d i n c o nnectio n w ith m y pen din g a ctio n f o r d is so lu tio n o f m arria g e. D ate : _ _ ________________ ________________________________ A c o py o f t h is a u th oriz atio n i s a s e ffe ctiv e a s t h e o rig in al.