Fill and Sign the Patient Release Authorization Form

PATIENT AUTHORIZATION FOR RELEASE OF INFORMATION TO: (Health Care Provider) RE: (Client) Date of Birth: ____________________ Social Security No.: ____________________ This is your full and sufficient authorization, pursuant to Minn. Stat. Sec. 144.335, to release to: (Name of Attorney) , his/her representatives or employees, all medical, psychological, or other information (including but not limited to that which involves treatment for alcohol or drug abuse, sickle cell anemia, or mental problems) maintained while I or my minor dependents were patients or in treatment at your facility on any date, with the following exceptions: ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ This information is needed for the purpose of the court proceeding regarding dissolution of marriage, child custody, and visitation. 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 between (Name of Attorney) and his/her agents and medical personnel are also authorized by this release. ______________________________ ____________ Signature of Patient Date 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. ______________________________ ____________ Signature of party requesting Date - 1 - ATTENTION PUBLIC FACILITIES: Minnesota Statutes Sec. 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. - 2 -