MNCP ROI - eSignature
393 North Dunlap Street #300
Saint Paul, MN 55104
P: 612-289-5656 F: 651-925-0278
First Name M.I Last Name
Maiden or Other Known Name Date of Birth
Daytime Phone Parent/Guardian
I give permission for the following entities to exchange information:
Relation to the client
Information to be Released
Important: Indicate only the information that you are authorizing to be released.
OR to only release specific portions of your health information, indicate categories to be released
Health information includes written and oral information. By indicating any of the categories above, you are giving permission for written information to be released, and for the above ensures to speak to each other about your health information.
Reason(s) for releasing information (Please choose one or more):
I understand that by signing this form, I am requesting that the health information specified on this form be exchanged with the third party named on this form. I may stop this consent at any me by writing to the organization(s), facility(ies) and/or professional(s) named above. If the organization, facility or professional named above has already released health information based on my consent, my request to stop will not work for that health information. I understand that when the health information specified above is sent to the third party named above, the information could be re-disclosed by the third party that receives it and may no longer be protected by federal or state privacy laws. I understand that if the organization named above is a health care provider they will not condition treatment, payment, enrollment or eligibility for benefits on whether i sign the consent form.
This Consent will end one year from the date the form was signed unless I indicate an earlier date or event here:
Date: or Specific Event
Authorized Representative's signature
Relationship to Client
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: MNCP ROI - eSignature
Agree & Sign