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Collects patient identifiers, contact details, dates of service, diagnosis or condition information, and optional transfer instructions. Enables selection of record types (e.g., provider notes, billing statements, imaging, labs, medications, immunizations) and special permissions for federally protected categories. Includes purpose for release, delivery method preferences (portal, secure email, fax, mail), and authorization validity with revocation guidance.",{"@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/patient-authorization-and-records-release-form/194902/",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/patient-authorization-and-records-release-form/194902.png","ImageObject",442,249,{"name":88,"@type":89},"8796093062539","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-08","2026-09-03",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 information does the form collect from the patient?","Question",{"text":109,"@type":110},"It collects patient name, previous name (if any), street address, city/state/ZIP, phone number, date of birth, and details needed to identify and send the requested records.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How does the patient choose which records to release?",{"text":114,"@type":110},"The form provides checkboxes to select record categories and allows requests for specific diagnoses/conditions, date ranges of service, or individual report types (such as labs, imaging, medication list, or provider notes).",{"name":116,"@type":107,"acceptedAnswer":117},"How long is the authorization valid, and can it be revoked?",{"text":118,"@type":110},"The authorization is valid for 1 year from the patient’s signature unless otherwise specified. It can be revoked by sending a written request to the appropriate HealthPartners Release of Information department.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},194902,1788443771,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":60,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":126,"read_time":9},8796093062539,"| Patient Information | Patient name |  |  |  |  |  |  | Previous last name (if any) |  |  |  |  |  | Phone number |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  | Street address |  |  |  |  | City |  |  |  |  |  | State | ZIP code |  |  |  |  | Date of birth |\n| Release my records from: |  HealthPartners |  |  |  |  |  |  |  | OR |  External/Outside facility (complete this section only if requesting outside records) |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  | Phone number |  |  |  | Fax number |  |  |  |  |\n|  | Specific HealthPartners facility (optional) |  |  |  |  |  |  |  |  | Street address |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  | City |  |  |  | State |  |  | ZIP code |  |\n| Send my records to: | Person/Business/Hospital/Clinic |  |  |  |  |  |  |  |  | Phone number |  |  |  | Fax number |  |  |  |  |\n|  | Street address |  |  |  |  |  |  |  |  | City |  |  |  | State |  |  | ZIP code |  |\n| Information to be released\u003Cbr>• check only what applies\u003Cbr>• there may be\u003Cbr>a charge for records\u003Cbr>• instructions\u003Cbr>on back of form | \u003Cbr>I want health records related to this diagnosis/condition \u003Cbr>I want health records for these dates of service \u003Cbr>I am requesting a summary of my care.(Summary of care requests include provider notes, imaging reports, medications, labs, immunizations, etc.)\u003Cbr>OR choose individual reports\u003Cbr>I only need the following individual reports/results:\u003Cbr>Billing or Itemized statements Consult report\u003Cbr>Discharge summary\u003Cbr>Eye or Optical\u003Cbr>Emergency department notes HealthPartners Dental (give request to your dental clinic) History and physical Immunization record\u003Cbr>Lab or Pathology report Medication list\u003Cbr>Mental health records Operative report\u003Cbr>Pathology glass slides Provider note/clinic visit\u003Cbr>X-ray/Imaging report Radiology imaging (describe) Other\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Special Permissions | In compliance with federal law, special permission is required to release the following records:\u003Cbr> Programs for Change  Alcohol and Drug Abuse Program (ADAP)  Hutchinson SUD Program\u003Cbr>WISCONSIN RECORDS ONLY: Special permission is required to release the following records:\u003Cbr> HIV test results  Mental health  Developmental disability  Substance use disorder |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Purpose for release | \u003Cbr>Continuity of care Transfer of care |  |  | Personal/My request Insurance |  |  |  | Disability Legal |  |  Review current care\u003Cbr> Other   |  |  |  |  |  |  |  |  |\n| Release\u003Cbr>method |  Date records needed / /  | Onsite records pickup not available; choose one of the following options\u003Cbr> Release to my online account (patient portal) . Not available with all proxy access (see pg2, 7d).  Secure email  Indicate email address ONLY if you want your records sent via email.\u003Cbr>Email may be sent by copy service.\u003Cbr> Email address |  |  |  |  |  |  |  |  |  |  |  |  | | Fax\u003Cbr> Number   Mail |  |  |\n| Authorization and Revocation | • I authorize HealthPartners to release the information marked above. HealthPartners will not withhold treatment or insurance payment based on whether I sign this form.\u003Cbr>• Records released may include information received from other organizations.\u003Cbr>• Records released may no longer be protected by law and could be redisclosed by the recipient. Federal regulations prohibit the recipient of substance use disorder records from making any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted (42 .CFR.2.32) .\u003Cbr>• There may be a charge for records.\u003Cbr>• This authorization will be valid for 1 year from the date of my signature, unless a date, event or condition is otherwise specified.   \u003Cbr>• I may revoke this authorization by sending a written re","cbCaikhmA2CuV39v","https://ap.wps.com/l/cbCaikhmA2CuV39v","pdf",330214,"English","# Patient information\n## Release recipient and facility\n# Information to be released\n## Special permissions\n# Purpose and release method\n## Authorization and revocation","[{\"question\":\"What information does the form collect from the patient?\",\"answer\":\"It collects patient name, previous name (if any), street address, city/state/ZIP, phone number, date of birth, and details needed to identify and send the requested records.\"},{\"question\":\"How does the patient choose which records to release?\",\"answer\":\"The form provides checkboxes to select record categories and allows requests for specific diagnoses/conditions, date ranges of service, or individual report types (such as labs, imaging, medication list, or provider notes).\"},{\"question\":\"How long is the authorization valid, and can it be revoked?\",\"answer\":\"The authorization is valid for 1 year from the patient’s signature unless otherwise specified. It can be revoked by sending a written request to the appropriate HealthPartners Release of Information department.\"}]","Patient Authorization and Records Release Form | PDF"]