1 Sample Authorization for Release of Information

Section 1.5 Assess Sample Authorization for Release of Information

This tool is a sample authorization form that social service agencies can use when seek ing release of protected health information (PHI) for a client from a health care provid er or organization.

Time needed: 2 hours Suggested other tools: Section 6.2 Privacy and Security Risk Analysis

How to Use

1. Review the MN e-health page for current information on State and federal information and resources regarding health information privacy, confidentiality & security. The URL for the site is: http://www.health.state.mn.us/e- health/privacy/index.html

2. Within this site is the Minnesota Standard Consent Form to Release Information form (it is a PDF document). This is a standard patient consent form for a person to release their health information. Review and become familiar with this form, which meets federal HIPAA requirements.

3. Use this form when requesting PHI from health care providers.

Section 1 Assess—Sample Authorization for Release of Information - 1