Release of information

You can request that Park Nicollet release medical record information to another facility by completing an online "Authorization for Release of Information" (ROI) form. Select the appropriate form*, which most likely will be determined by where you received services. For examples, see below.

Form use

 ROI information sheet (PDF)

Use the Park Nicollet ROI form (PDF) when:

• you stayed overnight at Park Nicollet Methodist Hospital
• you were seen in the Emergency Center
• you were seen at outpatient surgery or an outpatient clinic
• you were seen at a Park Nicollet Clinic, Urgent Care or TRIA
• you are looking for mental health records

Use the  non-Park Nicollet records ROI form (PDF) when requesting records from outside Park Nicollet Health Services to be sent to Park Nicollet. 

*Note: Form load time may vary depending on the speed of your Internet connection. Please allow sufficient time for the form to load.

If you have questions regarding medical record release, refer to ROI frequently asked questions (PDF) or call Health Information Management, 952-993-7600, during business hours, 7 a.m. to 5 p.m. If you have questions regarding radiology images, call 952-993-5427, 7:30 a.m. to 6 p.m.

Complete and submit form

Ensure all form fields are filled out completely. Review and complete appropriate fields. Please sign the completed form. If your request is for continuation of care (future appointments or procedures), please fax, mail or drop off at the appropriate Park Nicollet location listed below. For all other requests, please mail or drop off at the appropriate Park Nicollet location. A fee may be charged if the request is for other than continuing care.

Permission to verbally discuss protected health information

Park Nicollet Health Services knows that privacy regulations have an impact on our customer service to you, especially when it comes to discussing information about you with family, friends and others you designate who are involved in your care. We have established a process that allows you to tell us who we may talk with about your medical care. This includes appointment information, lab and test results, treatment information and billing information. Print the form and instructions below, complete the information and mail it to us at the address listed. This is an optional form.

 Permission to verbally discuss protected health information (PDF)

Order birth certificates

To request a certified copy of a birth certificate, visit the Hennepin County Service Web site.