Fill and Sign the Mn Records Information

AUTHORIZATION TO RELEASE TREATMENT RECORDS, REPORTS, AND INFORMATION __________________ __________________ __________________ Telephone: __________________ Re: _____________________ DOB _____________________ SS# _____________________ This is full and sufficient authorization pursuant to Minnesota Statutes Section 114.335 to release to _____________________ of the law firm of _____________________ , _____________________ , _____________________ , _____________________ , _____________________ , or their employees or agents all information they may request, written or verbal, pertaining to any and all consultation, treatment, and counseling rendered to me. You may also allow the aforementioned or anyone appointed by them to examine any records, charts, reports, notes, or other recorded information regarding any consultation, treatment, and counseling rendered to me by you while. The records, reports, and information are needed for use in connection with my pending marriage dissolution action. I understand that I may revoke this consent at anytime and that upon fulfillment of the above-stated purpose, this consent will automatically expire without my express revocation. HIPAA Release Authority. My agent shall be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160 through 164. I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company, and the Medical Information Bureau, Inc. or other health care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose and release to my agent, without restriction, all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, including all information relating to the diagnosis of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. The authority given my agent shall supersede any other agreement that I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information. Dated: __________________ _______________________________ Client - 1 - I verify that the proceeding in which this information is required is still pending and that information provided pursuant to this authorization will not be re-released for purposes not related to this proceeding. Dated: __________________ _______________________________ _____________________ Attorney for Petitioner ATTENTION PUBLIC FACILITIES: Minnesota Statutes Section 13.05, subd. 4, requires automatic expiration of this authorization one year from the date of this authorization. - 2 - AUTHORIZATION NAME: _____________________ _____________________ TITLE: __________________ Manager ADDRESS: __________________ __________________ __________________ Telephone: __________________ RE: __________________ __________________ __________________ TO WHOM IT MAY CONCERN: YOU ARE HEREBY AUTHORIZED to give the law firm of _____________________ , _____________________ , _____________________ , Minnesota _____________________ , and any of the attorneys, legal assistants, or agents employed by that firm, any and all information that you have pertaining to my participation in the _____________________ Plan any and all benefits to which I am or may be entitled as a participant in that fund, including but not limited to the following: 1. Amount of contributions I have made to date, 2. The number of years, months, and days of participation, 3. Date of vesting, 4. The accrued vested monthly benefit, 5. The current balance in the account, 6. The estimated monthly benefit upon retirement, 7. The amount of interest that has accrued on the account, 8. The amount of any employer contribution to the account. You are further authorized to allow said persons to examine and copy any and all documents containing such information and to deliver copies of any and all pertinent documents to said law firm. This authorization will automatically expire at the end of one year unless expressly revoked by me in writing before that time. Dated: __________________ __________________________ _____________________ - 3 - PATIENT AUTHORIZATION FOR RELEASE OF INFORMATION TO: __________________ (For use by lawyers and law offices) __________________ __________________ RE: __________________ (Patient's name) __________________ (Date of birth and/or Soc. Sec. #) This is your full and sufficient authorization, pursuant to Minn. Stat. Section 144.335, to release to: __________________ their representatives or employees, all medical information (including but not limited to that which involves treatment for alcohol or drug abuse, sickle cell anemia, or mental problems) maintained while I was a patient at your facility on any date, with the following exceptions: _____________________ _____________________ . This information is needed for the purpose of: _____________________ . This authorization specifically includes records prepared prior to the date of this authorization and records prepared after the date of this authorization during the pendency of this proceeding (including claims and potential claims). I do not authorize re-release of this information by the third party. I understand that I may revoke this consent in writing at any time, but that such revocation may adversely affect the course of the proceeding requiring these records. Upon the fulfillment of the above stated purpose, this consent will automatically expire without my express revocation. A photocopy of this authorization will be treated in the same manner as an original. Conversations by the bearer of this authorization with physicians, however, are/are not (strike one) authorized by this release form. _________________________ ______ Signature of Patient/Guardian Date __________________________________________ Relationship to Patient __________________________________________ Reason Patient unable to sign I verify that the proceeding requiring this information is still pending and that information provided pursuant to this authorization will not be re-released for purposes not related to this proceeding. - 4 - __________________________ ______ Signature of party requesting Date information ATTENTION PUBLIC FACILITIES: Minnesota Statutes Section 15.163 requires automatic expiration of this authorization one year from date of authorization. Form approved by Minnesota State Medical Association, Minnesota State Hospital Association, Minnesota State Bar Association, and Minnesota Association of Hospital Attorneys. - 5 - AUTHORIZATION TO RELEASE FINANCIAL RECORDS, REPORTS AND INFORMATION TO: __________________ (For use by lawyers and law offices) __________________ __________________ RE: __________________ (Patient's name) __________________ I do hereby authorize the above-named to release to _____________________ , their employees, agents, or representatives, any and all banking records, as may be requested by them in connection with my pending action for dissolution of marriage. This authorization will automatically expire one year from the date of the authorization unless earlier revoked by me. Date: __________________ ________________________________ I verify that the proceeding in which this information is required is still pending and that information provided pursuant to this authorization will not re-released for purposes not related to this proceeding. Dated: __________________ ________________________________ - 6 - AUTHORIZATION TO: __________________ (For use by lawyers and law offices) __________________ __________________ RE: __________________ (Patient's name) __________________ I hereby authorize the __________________ or its agents to release the information specified below concerning __________________ to __________________ , Attorney at Law, __________________ , Minnesota, _____________________ : A copy of this authorization shall be equivalent to the original. Dated: __________________ ______________________________ I verify that the proceeding in which this information is required is still pending and that information provided pursuant to this authorization will not re-released for purposes not related to this proceeding. Dated: __________________ ____________________________________________________ - 7 - AUTHORIZATION TO RELEASE MEDICAL AND/OR RECORDS, REPORTS, AND INFORMATION TO: __________________ (For use by lawyers and law offices) __________________ __________________ RE: __________________ (Patient's name) __________________ This is full and sufficient authorization pursuant to Minnesota Statutes Section 114.335 to release to _____________________ , and any and all attorneys, legal assistants, and agents thereof, all information they may request, written or verbal, pertaining to any and all consultation, treatment, and counseling rendered while I was a patient or client. You may also allow the aforementioned or anyone appointed by them to examine any records, charts, reports, X-rays, or other recorded information regarding any consultation, treatment, and counseling rendered by you while I was a patient or client. The records, reports, and information are needed for use in connection with my pending marriage dissolution action. I understand that I may revoke this consent at any time and that upon fulfillment of the above- stated purpose, this consent will automatically expire without my express revocation. Dated: __________________ __________________________________ Patient Client I verify that the proceeding in which this information is required is still pending and that information provided pursuant to this authorization will not be re-released for purposes not related to this proceeding. Dated: __________________ ___________________________________ Attorney ATTENTION PUBLIC FACILITIES: Minnesota Statutes Section 13.05, subd. 4, requires automatic expiration of this authorization one year from the date of the authorization. - 8 - AUTHORIZATION TO RELEASE FINANCIAL RECORDS, REPORTS AND INFORMATION TO: __________________ (For use by lawyers and law offices) __________________ __________________ RE: __________________ (Patient's name) __________________ I, _____________________ , do hereby authorize the above-named accountants to release to my attorney, _____________________ , their employees, agents, or representatives, and to the accounting firm of _____________________ , their employees, agents, or representatives, any and all financial records, tax returns, reports and information pertaining to _____________________ as may be requested by them for the purpose of valuing the firm and my interest therein in connection with my pending action for dissolution of marriage. Date: __________________ ________________________________ William J. Schmidt I verify that the proceeding in which this information is required is still pending and that information provided pursuant to this authorization will not be re-released for purposes not related to this proceeding. Dated: __________________ ___________________________________ _____________________________ Attorney for _____________________ - 9 - AUTHORIZATION TO RELEASE PRIVILEGED RECORDS, REPORTS AND INFORMATION TO: __________________ (For use by lawyers and law offices) __________________ __________________ RE: __________________ (Patient's name) I, _____________________ , do hereby authorize the above-named attorney to release to my present attorney, _____________________ their employees, agents, or representatives any and all files, pleadings, documents, records, reports and information pertaining to any criminal proceedings brought against me. I further authorize the above-named attorney to confer with and disclose to _____________________ , their employees, agents, or representatives any information whether or not subject to the client-attorney privilege, as may be requested by them. Date: __________________ _______________________________ I verify that the proceeding in which this information is required is still pending and that information provided pursuant to this authorization will not be re-released for purposes not related to this proceeding. Dated: __________________ ____________________________________ - 10 - AUTHORIZATION TO RELEASE FINANCIAL RECORDS, REPORTS AND INFORMATION TO: __________________ (For use by lawyers and law offices) __________________ __________________ RE: __________________ (Patient's name) __________________ I, _____________________ , do hereby authorize the above-named to release to the attorney, _____________________ , their employees, agents, or representatives, any and all financial statements, statements of account, financial records, reports and any other financial information pertaining to _____________________ and _____________________ as may be requested in connection with my pending action for dissolution of marriage. Date: __________________ ________________________________ A copy of this authorization is as effective as the original. - 11 -