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Release of Information
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:
701-683-4345 - 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