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Allina Hospitals & Clinics / Buffalo Hospital / Medical record / United Hospital / Health informatics / Medical informatics / Medicine / Health


ALLINA HEALTH AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION PATIENT INFORMATION NAME: ______________________________________________________ DATE OF BIRTH: ______________________ Address: ____________________
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Document Date: 2013-10-30 11:18:10

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File Size: 152,71 KB

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City

Lakeville / Minneapolis / St. Paul / Buffalo / Shoreview / /

Company

Aspen Medical Group / /

Facility

Allina Medical Clinic / Allina Health Pharmacy Charges Copies Allina Health Pharmacy / Allina Health hospital / United Hospital / Bandana Square / Buffalo Hospital / Quello Clinic / /

/

MedicalCondition

injury / Immunization/allergy / illness / /

MedicalTreatment

Immunization / immunizations / /

Organization

Receiving Party / Buffalo Hospital / Allina Health Corporate Office in Minneapolis / Allina Health hospital / Date Authority / United Hospital / /

/

Position

Immunization/allergy record Chemical dependency/ Operative / /

ProvinceOrState

Minnesota / /

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