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Click here or scroll down to respond to this candidate 1. Patient NAME Donald McCabe Office Use Only MRN
Information
Street Address 12 1941 PHONE NUMBER AVAILABLE EMAIL AVAILABLE
Date of Birth Day phone Email
2. Health Care NAME/ORGANIZATION Essentia Health Phone
PHONE NUMBER AVAILABLE
Provider or Clinic or
Hospital who has Address
3000 32nd Avenue S Fax
the information you Fargo ND 58103
want released? City State Zip
3. Where do you want NAME/ORGANIZATION Candidate's Name Diane
Attention
the information to 3704 42nd St S, 313 PHONE NUMBER AVAILABLE
be sent? Address Phone
City
Fargo State
ND 58104
Zip
Fax Number
4. Why is it needed? Continuing care Workers Compensation* School Personal use*
Insurance application* Insurance payment/claim* Legal* Other
5. What are the December 18, 2023
Service Dates Between __________________________ December 22, 2023
to___________________________
approximate dates Send All Routine Records
of information you
Notes, History and Physical, Discharge Summary, Emergency Room, Lab, Radiology, Procedures, Test Results and Consultations
want released?
Or Send Other Records
Discharge Summary Diagnostic Test Results Consultations Radiology Reports
What do you want History and Physical Exams Pathology Reports Psychological Testing Laboratory Reports
released?
Operative/Procedure Reports Progress/Provider Notes HIV/Aids Testing Emergency Reports
Rehab Reports (PT/OT/SP) Chemical Dependency/Substance Abuse Reports Form Completion
Choose Routine for
items a health care Medication List Other (specify content and dates)
provider typically Radiology Films/MRI Billing Records Pathology Slides (are sent directly to the facility listed in step 3)
needs, or select
individual records.
All information regarding alcohol and/or drug abuse or behavioral health will be released unless you restrict by initialing:
Do not release alcohol and/or drug abuse information Do not release behavioral health information
6. When is Date the information is needed? 01 / 30 / 2024 Or Date of the appointment? / /
it needed?
To check on the status of your copies, please email EMAIL AVAILABLE or call PHONE NUMBER AVAILABLE
7. How do you want Release Method / Format requested:
the information? For copies: MyChart or Paper or CD/DVD or Fax
Pick up (Photo ID is required at pickup time) Verbal (no copies) For Films/MRI: CD/DVD
This authorization lasts for one year after the date you sign it unless you enter a different expiration date here: .
I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified except to
the extent action has already been taken in reliance on it.
I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal
privacy regulations.
I understand this consent for release of alcohol and/or drug abuse information is subject to revocation at any time except to the extent that the program or person
which is to make the disclosure has already acted in reliance on it.
I understand that Essentia Health may not condition my treatment, payment, enrollment, or eligibility for benefits on my signing this authorization.
I understand, upon request, I will receive a copy of this form after I have signed it.
I understand that in compliance with MN Statute 144.293, WI Administrative Code HHS117, NDCC 23-12-14, Federal Rule 45 CFR 164.524; Charges may apply in
ID. I may be required to pay a fee for retrieval and photocopying of records and/or supervising inspection of medical records.*
I understand a photocopy or fax of this form is the same as the original.
8. Patient Signature and
Date are required to
release records. If an Jan 16, 2024
Authorized Person is
signing you must include
Signature of Patient or Authorized Person Date
legal documentation. Parent of Minor Court-appointed guardian/conservator (Include legal documentation)
Email: Mail to: Essentia Health Telephone Number: PHONE NUMBER AVAILABLE Fax Number: PHONE NUMBER AVAILABLE
EMAIL AVAILABLE PO Box 19058 (Use this fax number to submit
Green Bay WI 54307 only Authorization Forms.)
Adobe Sign Authorization For Use and Disclosure of
Protected Health Information
EH13459 05/21 Page 1 of 1
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