• To print a blank form, click the "Print Blank Form" button below.
  • Otherwise, complete the form online, and use the 'View/Print PDF'  button to print a completed form at the end.

Contact Person / Organization

Record(s) Requested

* The record(s) will be used:

Release / Obtain the following information / records

Expiration

Client Authorization and Signature

The information may be shared unless otherwise indicated, orally, in writing, or electronically.

  • I have the right to refuse to sign this authorization. Treatment, payment or operations are not conditioned on my authorization.
  • I may cancel this authorization at any time by contacting my worker if the release has not already been carried out. (Workers: use form HC12025 to document.)
  • A copy of this authorization is as valid as the original.
  • I may be required to pay the actual costs of making, certifying and/or compiling the copies of information requested.
  • After this information is released, it may be re-released to a third party if allowed by law. However, 42 CFR Part 2 prohibits unauthorized re-release of substance use disorder records.
  • If I have questions about the privacy of my records, I may ask my worker for more information.
If not signed by subject of disclosure, specify basis for authority to sign:

The information is available in other forms to people with disabilities. Call the county worker or contact the worker through the Minnesota Relay Service at 1-800-627-3529 - TTY