Release of Protected Health Information (ROI)



A place for non-surgical treatment of back and neck pain and other musculoskeletal issues.
Pain doesn’t need to be a constant part of your life. The team at MIPM strives to get to the root of your pain to help you feel better.

 
Patients Information
Printed Patient's Legal Name(Required)
MM slash DD slash YYYY

Please release my records from and to: (Who has or needs your records? Please list the hospital, clinic and/or entity.)
1.
Name(Required)
Address
2.
Release the records marked below for this condition or date(s) of treatment:

 

(if blank, we will release 1 year’s worth of most recent records.) Please check records to be released:
Type of Claim (Click One):

3.
Purpose: (Click One)

Purpose: (Check Mark)
4.

I understand that:
The release of records listed in Section 2 may include detailed information of treatment for mental health, chemical dependency, genetic conditions, and AIDS/HIV.

If I have received treatment for any of these conditions, may these records be included (Check One)

If I change my mind, I may write to Minnesota Institute for Pain Management at the address at the top of this release to stop
the release of my records. This will not apply to records that have already been released.

Once the records are released to the name above, the place releasing my records cannot prevent them from being shared with a third party. At that point, the records may no longer be protected by state and federal privacy laws.

A photocopy of this completed signed form is considered valid if not altered.
I understand that, except for research related treatment, you will not condition my treatment, payment, enrollment, or eligibility for benefits on my signing this authorization.

 

MM slash DD slash YYYY
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Reset signature Signature locked. Reset to sign again