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MNCP ROI - eSignature

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Minnesota CarePartner
393 North Dunlap Street #300
Saint Paul, MN 55104
P: 612-289-5656 F: 651-925-0278

Release of Information

Patient Information

First Name M.I Last Name

Maiden or Other Known Name Date of Birth

Home Address

Daytime Phone Parent/Guardian

I give permission for the following entities to exchange information:

Minnesota CarePartner
393 North Dunlap Street #300
Saint Paul, MN 55104
P: 612-289-5656 F: 651-925-0278

AND

Name
Address
Phone Fax
Relation to the client

Information to be Released

Important: Indicate only the information that you are authorizing to be released.

Specific Dates/ Years of treatment

All Health information

OR to only release specific portions of your health information, indicate categories to be released

History/Physical

Evaluations

Billing Records

Diagnostic Assessment

Progress Notes

Insurance Information

Discharge Summary

Functional Assessment

Other

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.

if you DO NOT want to give your permission for verbal communication

Reason(s) for releasing information (Please choose one or more):

Review client's current care	Payment	Other
Client's request	Legal
Treatment/continued care	Social Security Administration

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

Client Signature

Date

Authorized Representative's signature

Date

Printed Name

Relationship to Client

Witness Signature

Date

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

September 20, 2021 3:08 pm CDT

MNCP ROI - eSignature Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 206.84.188.12