CHI Lisbon Health

A ministry of healing since 1952

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Securing the Promise : Quality Healthcare for the Region
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Release of Information

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Authorization for Use or Disclosure of Protected Health Information Access to Protected Health Information Form

In order to process your request for medical records, please complete all the  fields on the ‘Authorization for Release of Information’ form.   Please pay careful attention to complete all areas of the form.  If not completed, we may need to return your request for more information.

Please call (701) 683-6400 with questions about release of medical records or if you need assistance completing the authorization form.

Once you have completed and signed the form(s), utilize one of these options:

  • Fax it to:
  • Mail it to:
    CHI Lisbon Health
    905 Main Street
    Lisbon, ND 58054

Return it to the facility Registration Office and the authorization will be hand delivered to the HIM Department and your request processed.

Thank you,

CHI Lisbon Health HIM Department

Securing the Promise : Quality Healthcare for the Region