Release of Information

Native American Community Clinic

Authorization for Disclosure of Health Information/Patient Request Access to Patient Health Information
This authorization will remain active for 12 months unless revoked in writing.*

Please process this request as soon as possible. Please keep authorization on file for future disclosures.Please process this request as soon as possible. I do not authorize future disclosures.Please do not process this authorization immediately. It should be kept on file for future disclosures.
Patient Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
SSN
Last Four
Day Phone*
Please enter a valid phone number.
Evening Phone
Please enter a valid phone number.
Account Number
I authorize:*

NACC to send medical records to this organization.NACC to receive medical records from this organization.
Please enter the name of the Hospital/Clinic/Facility that will be sending/receiving your protected health information.*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Phone:*
Please enter a valid phone number.
Facility Fax:
Please enter a valid fax number.
Receiving Clinic Information

Native American Community Clinic

1213 E. Franklin Avenue

Minneapolis, MN 55404

Main Phone: 612-872-8086

Medical Fax: 612-872-8547

Behavioral Health Fax: 612-208-1305

Dental Fax: 612-871-4812
Information to be released:
Consent:*

I consent for information to be mutually exchanged verbally on the following criteria.I consent for medical records to be released based on the criteria.
Timeframe to Be Released:

Past 2 YearsTime Frame:
Please indicate the information to be released (check all that apply):*

Entire RecordDischarge SummaryPathology Report(s)History and PhysicalRadiology Report(s)Problem List, Medication List, Last Office VisitNeuropsych/Developmental TestingConsultation(s)Prenatal/Delivery RecordsLaboratory Report(s)Immunization HistoryEmergency Department Report(s)Preventative Care: Last Pap, Mammogram, and/or ColonoscopyOther
THIS INFORMATION IS TO BE RELEASED FOR THE PURPOSE OF:*

Continuity of CareTransfer of CareSocial Security/DisabilityPatient AccessInsurance ApplicationOther
DISCLOSURES/SPECIAL CONSENT: Incompliance with Minnesota Statutes which require special permission to disclose otherwise privileged information, I am authorizing the following information also be disclosed. Check all that apply:

Alcohol and Drug Abuse Program (ADAP)Mental health recordsHIV/STI recordsSubstance Use/Chemical Health Program
NOTE: A FEE MAY BE CHARGED IN ACCORDANCE WITH MN STATUTE 144.292 AND FEDERAL RULE 164.524

I understand that I may revoke this authorization at any time with written notification, but that the revocation will not have any effect on the information released prior to notification of revocation. Please see your Notice of Privacy Practices for information on how to revoke this authorization.

I also understand that this authorization will automatically expire one year from the date of my signature unless I revoke it earlier. NACC will not refuse or revoke my treatment if I choose not to sign this authorization. A photocopy/fax of this authorization will be treated in the same manner as an original. You may, in the presence of NACC Staff, inspect or copy the information for use or disclosure with this Authorization for Disclosure.

I understand that substance use disorder health information is protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 C.F.R. Parts 160 and 164, and cannot be disclosed without written consent unless otherwise provided for by the regulations.

Further, I realize that NACC cannot prevent the redisclosure of records released as a result of this request and that the records may not be subject to privacy rule protections; therefore, NACC is released from any and all liability resulting from redisclosure.
Patient/Legal Representative Signature*

Clear
Date*

MonthDayYear
Date
If other than patient, state relationship and authority to sign:
Should be Empty:

Native American Community Clinic

Information to be released: