This form was approved by the Commissioner of the Minnesota Department of Health on January 30, 2008 and updated in Feb. 2024 Feb. 2024
Instrucons for Minnesota Standard Consent
Form to Release Health Informaon
Important: Please read all instrucons and informaon before compleng and signing the form.
An incomplete form might not be accepted. Please follow the direcons carefully. If you have any quesons about the release of
your health informaon or this form, please contact the organizaon you will list in secon 3.
This standard form was developed by the Minnesota Department of Health as required by the Minnesota Health Records Act
of 2007, Minnesota Statutes, secon 144.292, subdivision 8. The form must be accepted by a Minnesota provider as a legally
enforceable request under the Minnesota Health Records Act. If completed properly, this form must be accepted by the health
care organizaon(s), specic health care facility(ies), or specic professional(s) idened in secon 3.
A fee may be charged for the release of the health informaon.
The following are instrucons for each secon. Please type or print as clearly and completely as possible.
1
Include your full and complete name. If you have a sux
aer your last name (Sr., Jr., III), please provide it in the “last
name” blank with your last name. If you used a previous
name(s), please include that informaon. If you know your
medical record or paent idencaon number, please
include that informaon. All these items are used to idenfy
your health informaon and to make certain that only your
informaon is sent.
2
If there are quesons about how this form was lled out, this
secon gives the organizaon that will provide the health
informaon permission to speak to the person listed in this
secon. Compleng this secon is oponal.
3
In this secon, state who is sending your health informaon.
Please be as specic as possible. If you want to limit what
is sent, you can name a specic facility, for example Main
Street Clinic. Or name a specic professional, for example
chiropractor John Jones. Please use the specic lines.
Providing locaon informaon may help make your request
more clear. Please print “All my health care providers” in this
secon if you want health informaon from all of your health
care providers to be released.
4
Indicate where you would like the requested health
informaon sent. It is best to provide a complete mailing
address as not everyone will fax health informaon. A place
has been provided to indicate a deadline for providing the
health informaon. Providing a date is oponal.
5
5 Indicate what health informaon you want sent. If you want
to limit the health informaon that is sent to a parcular
date(s) or year(s), indicate that on the line provided.
For your protecon, it is recommended that you inial
instead of check the requested categories of health
informaon. This helps prevent others from changing your
form.
EXAMPLE: All health informaon
If you select all health informaon, this will include any
informaon about you related to mental health evaluaon
and treatment, concerns about drug and/or alcohol use, HIV/
AIDS tesng and treatment, sexually transmied diseases and
genec informaon.
Important: There are certain types of health informaon that
require special consent by law.
Chemical dependency program informaon comes from
a program or provider that specically assesses and treats
alcohol or drug addicons and receives federal funding. This
type of health informaon is dierent from notes about a
conversaon with your physician or therapist about alcohol
or drug use. To have this type of health informaon sent,
mark or inial on the line at the boom of page 1.
Psychotherapy notes are kept by your psychiatrist,
psychologist or other mental health professional in a
separate ling system in their oce and not with your
other health informaon. For the release of psychotherapy
notes, you must complete a separate form nong only that
category. You must also name the professional who will
release the psychotherapy notes in secon 3.
6
Health informaon includes both wrien and oral
informaon. If you do not want to give permission for
persons in secon 3 to talk with persons in secon 4 about
your health informaon, you need to indicate that in this
secon.
7
Please indicate the reason for releasing the health
informaon. If you indicate markeng, please contact
the organizaon in secon 4 to determine if payment or
compensaon is involved. If payment or compensaon to the
organizaon is involved, indicate the amount.
8
This consent will expire one year from the date of your
signature, unless you indicate a dierent date or event.
Examples of an event are: “60 days aer I leave the hospital,”
or “once the health informaon is sent.”
9
Please sign and date this form. If you are a legally authorized
representave of the paent, please sign, date and indicate
your relaonship to the paent. You may be asked to provide
documents showing that you are the paent or the paent’s
legally authorized representave.