18534 - Authorization for Release of Information - Park Nicollet 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, previous last name (if applicable), street address, city, state, ZIP code, and phone number in the designated fields.
3. Select the information you wish to be released by checking the appropriate boxes for medical records, clinic visit notes, mental health records, and any other relevant categories.
4. Specify the dates for which you are requesting records in the 'Records concerning/Dates requested/Special instructions' section.
5. Indicate to whom the information should be released by filling out the facility/provider/insurance company/attorney/patient name field.
6. Choose your preferred method of delivery for each type of record—options include mail, secure email, or pick-up.
7. If you are signing on behalf of the patient, ensure to indicate your relationship and reason for signing. Finally, review all entered information before clicking 'PRINT' to finalize your submission.

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