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Authorization to Release Patient Information

IMPORTANT: Please be aware that not all personal emails are secured. For this reason, due to Federal HIPAA* regulations please do not include personal health information in your correspondence.

A patient, or his/her legal representative, may inspect and/or obtain a copy, request an amendment or have copies of medical records sent to another facility. United Hospital District requires a completed and signed authorization for realease of health information form before releasing any documents.

To request a copy of your medical record:

  • Download, print and complete this Authorization for Release of Information form.
  • We ask that you specify which components of your medical records you wish to obtain.
  • Please indicate on the form how you would like to receive the records. They can be mailed to you or you can pick them up.
  • Release of Information Fax: 507-526-2467
    Release of Information Phone: 507-526-7981

    If you have any other questions or concerns regarding release of health information, please call 507-526-7981.

    *Health Insurance Portability and Accountability Act (HIPAA) protects the security and privacy of health data.

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