Release of Information

Requesting Your Medical Records:

  1. Click here to download and print the Release of Information form
  2. Authorizations must be signed by the patient (age 18 or older), parent of a minor patient (age 0-17) or the patient’s legal representative.
  3. For authorizations signed by the legal representative, documents indicating the representative’s legal authority must be provided. Documentation may be a health care power of attorney for health care decision making, a court appointed guardianship or other similar legal documentation.
  4. Fill out the form as completely as you can and mail to:

Release of Information
PO Box 603
Crookston, MN 56716

Or, fax to 218.281.6261 (Attn: Release of Information)

For additional information about Release of Information, call 218.281.3940 and ask to speak to Medical Records.

603 Bruce Street | Crookston, MN 56716
© Northwestern Mental Health Center 2019