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The guide explains that an incomplete form may be rejected and that Minnesota providers must accept the form under the Minnesota Health Records Act. It covers optional and required fields across sections, including patient identification, contact for completion questions, sending and delivery details, selecting categories and limits of health information, special consent categories, permitted disclosures, expiration rules, and signature requirements for patients or authorized representatives.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/minnesota-standard-consent-form-to-release-health-information/307614/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/minnesota-standard-consent-form-to-release-health-information/307614.png","ImageObject",442,249,{"name":88,"@type":89},"Stanley","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-07","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",6,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What should be done before completing and signing the Minnesota consent form?","Question",{"text":109,"@type":110},"Read all instructions and information carefully before completing and signing the form. 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Please follow the directions carefully. If you have any questions about the release of your health information or this form, please contact the organization you will list in section 3.  \nThis standard form was developed by the Minnesota Department of Health as required by the Minnesota Health Records Act of 2007, Minnesota Statutes, section 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 healthcare organization(s), specific health care facility(ies), or specific professional(s) identified in section 3.  \nA fee may be charged for the release of the health information.  \nThe following are instructions for each section. Please type or print as clearly and completely as possible.  \n1  \n2  \n3  \n4  \n5  \nInclude your full and complete name. If you have a suffix after your last name (Sr., Jr., III), please provide it in the “lastname” blank with your last name. If you used a previous name(s), please include that information. If you know your medical record or patient identification number, please include that information. All these items are used to identify your health information and to make certain that only your information is sent.  \nIf there are questions about how this form was filled out, this section gives the organization that will provide the health information permission to speak to the person listed in this section. Completing this section is optional.  \nIn this section, state who is sending your health information. Please be as specific as possible. If you want to limit what is sent, you can name a specific facility, for example Main Street Clinic. Or name a specific professional, for example chiropractor John Jones. Please use the specific lines. Providing location information may help make your request more clear. Please print “All my health care providers” in this section if you want health information from all of your healthcare providers to be released.  \nIndicate where you would like the requested health information sent. It is best to provide a complete mailing address as not everyone will fax health information. A place has been provided to indicate a deadline for providing the health information. Providing a date is optional.  \n5 Indicate what health information you want sent. If you want to limit the health information that is sent to a particular date(s) or year(s), indicate that on the line provided.  \nFor your protection, it is recommended that you initial instead of check the requested categories of health information. This helps prevent others from changing your form.  \nEXAMPLE: All health information  \nIf you select all health information, this will include any information about you related to mental health evaluation and treatment, concerns about drug and/or alcohol use, HIV/ AIDS testing and treatment, sexually transmitted diseases and genetic information.  \nImportant: There are certain types of health information that require special consent by law.  \nChemical dependency program information comes from a program or provider that specifically assesses and treats alcohol or drug addictions and receives federal funding. This type of health information is different from notes about a conversation with your physician or therapist about alcohol or drug use. To have this type of health information sent, mark or initial on the line at the bottom of page 1.  \nPsychotherapy notes are kept by your psychiatrist, psychologist or other mental health professional in a separate filing system in their office and not with your other health information. For the release of psychotherapy notes, you must complete a separate form noting only that category","cbCaiiCcwW7YPig5","https://ap.wps.com/l/cbCaiiCcwW7YPig5","pdf",253206,"English","# Instructions by Section\n## Section 1: Patient Information\n## Section 2: Contact for How the Form Was Filled Out\n## Section 3: Requesting Release of Health Information\n## Section 4: Where Information Will Be Sent\n## Section 5: What Health Information to Send\n## Sections 6-9: Communication Limits, Reason, Expiration, Signature","[{\"question\":\"What should be done before completing and signing the Minnesota consent form?\",\"answer\":\"Read all instructions and information carefully before completing and signing the form. An incomplete form might not be accepted, so follow the directions in each section.\"},{\"question\":\"Which sections cover patient identification and the optional contact for form completion questions?\",\"answer\":\"Section 1 collects full name and identifiers such as medical record or patient ID, plus birth date and address details. Section 2 is optional and lets you authorize a contact who can answer questions about how the form was completed.\"},{\"question\":\"How long does the consent last, and what must be included to make it valid?\",\"answer\":\"The consent expires one year from the date of your signature unless you indicate a different date or event. You must sign and date the form, and if you are a legally authorized representative, include your relationship and any required supporting documents.\"}]","Minnesota Standard Consent Form to Release Health Information | PDF",1789851968]