Name: Office Hours & Info
Address: 1525 31st Ave. SW / Suite E, Minot, ND, 58701, US
Telephone: +1 701-857-6050
Price range: Call for pricing options

Authorization For Release of Identifying Health Information
Name*
First Last
Date of Birth*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
I authorize to release health information identifying me (including, if applicable, information about substance abuse, mental health conditions, and HIV infection or AIDS) under the following conditions:
Information to be released:
Record requested from:
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Release information to…
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
*
- I acknowledge Johnson Eyecare PC does NOT utilize secure email and requesting to have my records released to me through their email system could pose a risk to my security and privacy. I will not hold Johnson Eyecare PC responsible for any security breach of my private health record transported in this manner.
Purpose of release
Expiration date for the release (if applicable)
It is completely your decision whether or not to sign this authorization form. We will not refuse to treat you if you choose not to sign this authorization. If you sign this authorization, you may revoke it at any time by contacting in writing, FAX or email the Privacy Official noted in the Notice of Privacy Practices.

When your health information is disclosed under this authorization, the recipient has no duty to protect its confidentiality. The recipient may re-disclose the information as he/she wishes.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.
Representative
- Check if you are signing as a representative to the patient
Date
Signature
Representative
Relationship to Patient
Upload an image of your driver's license*
Max. file size: 1 GB.
Name
This field is for validation purposes and should be left unchanged.

Office Hours & Info

Monday
8:30am - 5:00pm

Tuesday
8:30am - 5:00pm

Wednesday
8:30am - 5:00pm

Thursday
8:30am - 5:00pm

Friday
*8:30am - 2:00pm

Saturday
Closed

Sunday
Closed

Holiday Hours

Jan 1 - Closed

March 29 - Closing at 3pm

May 27-Closed

July 4-5 - Closed

Sept 2 - Closed

Nov 28 & 29 - Closed

Dec 24-27 - Closed

Jan 1 - Closed (2025)

1525 31st Ave. SW / Suite E
Minot, ND
58701

701-857-6050 701-857-6052

After-Hours Emergencies:

701-409-0076

Authorization Release Form

Authorization For Release of Identifying Health Information

Record requested from:

Release information to…

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