6600 Excelsior Boulevard · Suite 171 · St. Louis Park, MN  55426 · Phone 952-931-9718 · Fax 952-931-2236

INSTRUCTIONS

Make sure all blanks are filled in; failure to do so may prevent or delay release of information. Read our policy about obtaining copies of medical records printed at the bottom of this form. The release of records or information may be subject to a charge.

PATIENT

INFORMATION

(please print)

Name __________________________________________________________________________ 

DOB _______________________________    SS# ______________________________________

Address ________________________________________________________________________

Phone:  H: __________________   W: ____________________  Cell: ______________________

RELEASING  FACILITY/PHYSICIAN

FACILITY/

Physician Name: _________________________________________________________________

Address ________________________________________________________________________

RELEASE

INFORMATION

TO:

Physician Name: _________________________________________________________________

Address ________________________________________________________________________

INFORMATION

TO BE RELEASED:

(   )  Physician Notes

(   )  Medical History    

(   )  X-ray  Reports

(   )  X-ray Films

(   )  Operative Reports 

 (   )  My records relating to the diagnosis and/or treatment for alcoholism and/or drug  abuse/dependence, mental health, or HIV/AIDS may be released to the recipient noted on the consent above.

(   )  Laboratory reports

(   )  Diagnostic test reports

(   )  Information required for the completion

        of the attached form

(   )  Other ____________________________

EXTENT OF INFORMATION TO BE RELEASED

(   )  Including all dates of treatment

(   )  Treatment for  specific injury relating to  _____________________

(   )  Between dates of ________________ to _____________________

(   )  Only records of Dr. ______________________________________

REASON:

(   )  Patient’s own review

(   )  Insurance claim payment or application

(   )  Appointment with another MD

Date of appointment _____________________

(   )  Moving

(   )  Legal  (Explain)  ___________________ _____________________________________

(  )   Other ___________________________

I understand that this authorization will remain in effect 1 year from the date of signature.  I also understand that it may be revoked by me, in writing, at any time but would not apply to any information already released in good faith.

_________________________________________________                         _______________________________________

Signature of patient, parent of minor, or legal representative                                                           Date

RECORDS FROM OTHER FACILITIES:  It is the policy or Orthopedic Surgical Consultants, P.A. to release only medical information documented/dictated by Orthopedic Surgical Consultants, P.A. health care providers.  If you have been treated by other health care providers and facilities, please contact them and make arrangements to release any information you may need.