612-863-6137
Go Back to Website
Authorization for Use of Disclosure of Protected Health Information
Home
>
Contact Us
> Authorization for Use of Disclosure of Protected Health Information
Patient Name
*
Telephone
*
Partner Name
Telephone
Address:
*
City:
*
State:
*
Zip:
*
Date of birth
*
Age:
*
I authorize release of my records from:
*
Physician Name:
*
Clinic Address:
*
City:
*
State:
*
Zip:
*
I authorize release of my records to:
Center for Reproductive Medicine
2828 Chicago Ave. S., Suite 400
Minneapolis, MN 55407
Phone: 612-863-5390 Fax: 612-863-2697
Dr. Colleen Casey
Dr. Margaret Hopeman
Dr. Joshua Kapfhamer
Center for Reproductive Medicine
991 Sibley Memorial Hwy, Suite 100
St. Paul, MN 55118
Phone: 651-379-3110 Fax: 651-379-3111
Dr. Mark Damario
Information to be Released
We are interested in reviewing all information related to your prior fertility testing and treatment. Please send all records pertaining to fertility such as:
*
Progress Notes
Approximate Date
Lab Results
Approximate Date
Operative Reports
Approximate Date
Hysterosalpingogram FILM
Approximate Date
Genetic Testing
Approximate Date
Other
Purpose of Disclosure
Continuing Care
Insurance Application
Litigation
Insurance Payment
Personal
Other
Acknowledgement of Understanding
I understand the expiration date of this authorization is 1 year.
I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified except to the extent action has already been taken.
I understand that Center for Reproductive Medicine cannot prevent the redisclosure of records released as a result from this request; therefore Center for Reproductive Medicine is released from any and all liability resulting from redisclosure.
I understand by authorizing this use or disclosure of information, there will be no conditions placed on my health care or payment for my health care.
Signature of Patient or Personal Representative
*
Please use your mouse, stylus, or finger to sign your name in this box.
Relationship to Patient (if patient is unable to sign)
Date
*
Submit Form
Processing...
×
Alert
One fine body…