Health Records Release Form

Health Records Release Form
According to MN Statute 144.292 Subd.2 Affinity Care MN has 30 calendar days to process a written records release request
Program Participants Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Are you the Patient?*

YesNoNo (If not the program participant a ROI is required to be uploaded)
Upload Release of Information Form

Cancelof
Purpose of Record Request *
Date Range of Record Request
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Please select documents*

Medication RecordsProgress NotesDischarge SummaryIntake/45 Day/Annual AssessmentBehavioral ReportsMedical AssessmentsOther
How would you like your records delivered to you? Please indicate below:*

EmailU.S. Mail (Paper)Pick-up in Person
Where will records be sent? (Indicate email or address)*
I acknowledge that by electing to receive health information via email in a non-secure manner the information will not be encrypted and that it could be intercepted and viewed by a third party. Affinity Care is not responsible for unauthorized access to your health information while it is being transmitted to the email address you designated above.
- A request for substance use disorder and HIV-specific treatment records requires a separate authorization.
- A program participant will not be charged a fee for the first copy of the patient record but may be charged for additional copies of the same record.
Signature*

Clear
Name

First NameLast Name
Relationship to Program Participant*
Date*

MonthDayYear
Date
Affinity Care MN complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, gender identity, or sex.
Should be Empty:

Health Records Release Form

Date Range of Record Request