81 Request-for-Medical-Records by Client

REQUEST FOR MEDICAL RECORDS From Sioux Trails Mental Health Center
The following person has indicated that they have been a client of Sioux Trails Mental Health Center and has provided an Authorization to Release Protected Health Information.
Client Name(Required)
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I am requesting the following format:
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Information being requested
NOTICE: SMnBH may deny access to information under state and federal law in some circumstances. If SMnBH decides to deny access to all or part of the record, the decision to do so will be prompt and will advise reasons why and what options are available to file an appeal.
Our standard delivery time for records is 30 days but requests for extensive or non-recent records may take longer.
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Client or Legal Representative Signature(Required)
hereby waive Southern Minnesota Behavioral Health from the sole responsibility of maintaining the privacy of my medical record as by requesting my records from
Southern Minnesota Behavioral Health can no longer ensure what I do with my record and my protected health information. As always, Southern Minnesota Behavioral Health will not release any information without my consent, but cannot accept responsibility for any of the information that I share from my requested copy of medical record.
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New Ulm 1407 S. State New Ulm, MN 56073
Fax: 507-388-3199

the office closed September 1, 2023.
If you are looking for your medical record, please contact Counseling Services of Southern Minnesota, St. Peter.