Get the free MMHC Release of Information Form - Minnesota Mental Health Clinics

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Please print clearly and complete fully. *Patients 16 & older MUST sign all forms* **Use Blue or Black ink ONLY** Date: Provider:, Revised March 3, 2014, Intake Information PCN# Client's N an m e

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What is mmhc release of information?

MMHC release of information is a form used to authorize the disclosure of a patient's medical information by MMHC (My Medical Health Center).

Who is required to file mmhc release of information?

Patients or their legal representatives are required to file MMHC release of information.

How to fill out mmhc release of information?

To fill out MMHC release of information, the patient or legal representative must provide their personal information, specify what information can be disclosed, and sign the form.

What is the purpose of mmhc release of information?

The purpose of MMHC release of information is to ensure that patient medical information is only disclosed with proper authorization.

What information must be reported on mmhc release of information?

On MMHC release of information, the patient must specify which medical information can be disclosed, including diagnoses, test results, treatments, and medications.

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