Patient Authorization for Release of Protected Health Information

Release to myChart (patient portal) Email address Authorization • I authorize the HealthPartners Family of Care to release the information marked above. [...] I have the right to a copy of this form, and to inspect or obtain a copy of the health information disclosed. [...] • I may revoke this authorization by sending a written request to the appropriate HealthPartners Release of Information department (see section 8 on back of form). [...] Who has the information you want released? • If requesting records to be sent from a HealthPartners facility, see address list on bottom of page. [...] • Services provided after the date of signature may be released according to the authorization up until authorization expires.