CONSENT FORM

TO RELEASE HEALTH INFORMATION

1. Patient Information

First Name

Date of Birth

Last Name

Phone Number

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Email Address

2. I am requesting health information be released from:

Name of Organization

Street Address

City

Region/State/Province

Postal / Zip code

FAX

3. I am requesting the health information be sent to:

Miles Medication Management

Lisa Miles, APNP

3507 Lyndale Ave. S Minneapolis, MN 55408

**Please email (encrypted) here: lisaamiles@ptpmn.org

or fax (secure) here: 507-738-1963

4. Information to be released, please check all that apply

History/Physical

Medication

Mental Health Notes

Progress Notes

Lab Reports

5. Reason(s) for releasing information (please check)

Patient Request

Continued Care

Insurance

Legal Social Security

Other

Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effective for one year from date of execution at which time this authorization expires.

Revocation: This Authorization may be revoked by me or my personal representative at any time, but the revocation must be in writing and shall not apply to disclosures made before the revocation

6. Patients Signature

Patients Signature

Todays Date

OR, legally authorized representative’s signature

Todays Date

Representative relationship to patient (patent, guardian, etc.)

Add answer here

BACK TO FORMS

Thanks for submitting!

Phone: 612-708-7562

Fax 507-738-1963

lisaannmiles@mentalhealthmeds.org

3507 Lyndale Ave S.

Minneapolis, MN 55408

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