Secure patient form

Records release authorization

Use this form to let us request your records from the clinic that treats you. We'll ask them to fax your records to us at (701) 757‑0974. Records requests can take days or longer, so please send this early.

Please don't attach records to this form.

Required

Patient

First name

Last name

Date of birth

Phone

Other names your records may be under

For example, a previous last name.

Where your records are

Provider's name

The clinician who treats you, if you know.

Clinic or facility

City and state

Their phone

Their fax

What to request

Records that document your condition, or your recent lab work. Leave the dates blank to include all dates.

Which records?

Visit notes Specialist letters Test results and imaging reports Lab results Hospital discharge summaries Medication list

From

Purpose

This authorization expires on

For example, 12/31/2027, or one year from today.

Your rights

Signature

Typing your full legal name here is your electronic signature.

Today's date

If you are signing for the patient, your relationship to them

For example, parent, legal guardian or personal representative.

Sent privately to our care team