Form17 FR0123F Request-for-Medical-Records by Client REQUEST FOR MEDICAL RECORDS From Sioux Trails Mental Health CenterThe 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 First Middle Last Date of Birth MM slash DD slash YYYY PhoneAddress Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country I am requesting the following format: Paper sent to me at a physical address. Fax to a number. If you selected a paper sent to a physical address please type the address below: If you selected a fax to a number please type the number below: Beginning Date of information requested MM slash DD slash YYYY End Date of information requested MM slash DD slash YYYY Information being requested Intake Information Discharge Summary Diagnostic Assessment Progress Notes Treatment Plan Other 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.Date MM slash DD slash YYYY Client or Legal Representative Signature First Last If I signed as a Legal Representative, my relationship to the patient is: Cost I agree.SMnBH estimates that the cost of providing the record to be: _____________. In requesting the information, I agree to pay the reasonable charges for the record.CONSENTYour Name hereby waive Southern Minnesota Behavioral Health from the sole responsibility of maintaining the privacy of my medical record as by requesting my records from to 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. Signature First Last Date MM slash DD slash YYYY New Ulm 1407 S. State New Ulm, MN 56073 Phone: 507-354-3181 Fax: 507-354-3199Mankato 709 S Front St Mankato, MN 56001 Phone 507-388-3181 Fax: 507-388-3199
