4201 Exelsior Blvd

St. Luis Park , MN 55416

Telephone : (952) 800-9315

Fax : 952 945 9536




Patient's Name(First ,Last)

This will Authorize
To release information to *

Information to be released includes records from the following dates *

information to be released

Cardiac TestsEmergency department examinationOperative ReportsPhysician progress NoteAll records for the last yearConsultation reportsHistory & Physical ExaminationPathology ReportsRadiology FilmsDischarge SummaryLaboratory ReportsPhysician OrdersOther ( specify)

Reports related may include information regarding mental Status /Drug/Alcohol and HIV testing results. If there is specific information that do you not want released, please write it here *
This information is needed for the following purposes *

This authorization will expire upon the earliest of the following dates. 1)twelve months following date of signature on this form 2) the date the stated purpose is fulfilled 3)the date that I revoke this authorization at any time by writing a statement to the authorized releaser as noted above except to extent that life medical PA has relayed on the authorization.Aphotocopy or facsimile of the authorization shall be treated as valid as the origional.I understant that life medical PA will not condition treatment,payment,enrollment or eligibility forbenifits on whether I sign the consent form.I understand that once this information is disclosed ,it may no longer be protected under the federal privacy policy regulations and that the recipient might redisclose the information.

Name of patient *

If patient's representative ,under what legal authority are you signing *

ParentConservatorGaurdianHealth Care AgentOther

Specify (for other) *