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Release Of Information

First Name *:
Last Name *:
Birth Date *:
Release Information From
Family Services Rochester, 4600 18th Ave NW, Rochester, MN 55901, Fax 507-287-7805:
Other:
Specify facility/individual & address below, including phone/fax if known.:
Release Information To
Family Services Rochester, 4600 18th Ave NW, Rochester, MN 55901, Fax 507-287-7805:
Other:
Specify facility/individual & address below, including phone/fax if known.:
Purpose Of Release *:
Information to be Released:
If other was chosen, please specify:
Service Dates From (yyyy/yy/yy):
Services Dates To (yyyy/yy/yy):
• I understand that this authorization is voluntary and I am not required to sign it to receive healthcare services, payment, enrollment or eligibility for benefits.
• I understand that I may revoke this authorization at any time prior to its expiration date by submitting written notice of revocation to the releasing organization. I understand that my revocation will have no effect on any actions taken pursuant to this authorization prior to the revocation.
• I understand I have a right to receive copies of all information disclosed pursuant to this authorization.
• I understand that the information disclosed pursuant to this authorization may be further disclosed by the recipient
This Authorization will expire one year from the date of signing unless I indicate an earlier date or event below:
ATTENTION: This is a legal document. Please read carefully. By signing, you agree that you understand and accept the terms on this form.
Signature *:
Date Signed * (Month, DD, YYYY) :
Printed Name of Person Signing (If Personal Representative):
Relationship to Individual:
Mailing Address of Client- Street:
City:
State:
Zip Code:
Phone Number:
In addition to the authorization provisions above, I authorize the release of all information, data, notes, records, reports, and all other documents to the Requester, its consultants, experts, agents and/or other counsel relating to:
Signature *:
Date Signed * (Month, DD, YYYY):
Printed Name of Person Signing (If Personal Representative):
Relationship to Individual:
This form does not authorize re-disclosure of medical information beyond the limits of this consent. Where alcohol/drug abuse information has been disclosed through records that are protected by federal law, or mental health records protected by state law, further disclosure is prohibited without specific written consent of the patient or as otherwise permitted by such law and/or regulations. A general authorization is not sufficient for these purposes.

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