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Silverman Ankle & Foot - Edina Orthopedic Surgeon

Minnesota Foot & Ankle Surgeon

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Authorization Of Medical Release

In order to release your medical records, please look below and complete the form on-line. If you prefer to submit a paper copy, or require more detailed instructions, please click here.

Name *

First

Last

Previous Name (if applicable)

First

Last

Address

Date Of Birth

Phone Number

Email *

I am requesting that health information be sent to:

I hereby authorize, and request that the above facility/provider release copies of my medical information that are created and maintained by their facility to:

Body part(s) and/or dates of service requested:

Information to be released:

Medical Records
Itemized Billing
HIV/Mental Health/Drug Abuse Records
X-Ray (CD/Films)
Operative Note
Other (Please indicate in the next section)

IMPORTANT - Indicate only the information you are authorizing be released.

Other information to be released

If you checked "other" in the above section. Otherwise you may skip this section.

Verbal Disclosure of Information*

Verbal Disclosure Only

Please check here if you are completing this form for verbal communication consent ONLY to the parties listed in the "I am requesting that health information be sent to" section. Otherwise you can skip this section.

Reason For Releasing Information

Insurance
Workers' Compensation
Legal
Disability
Treatment/Continued Care
Patient's Personal Use

Date information needs to be received by:

Please allow at least two weeks for transfer.

I would like to receive my medical records by

Fax
Pick-up
Mail (pre-payment may apply)

Fax # (if you would like to receive via fax)

Mailing Address (if you would like to receive via mail)

I hereby authorize and request that Silverman Ankle & Foot release my health information that is created and maintained by SAF. I understand that I may revoke this consent at any time in writing. Revocation becomes effective once written request is received by SAF. This authorization will automatically expire in one year from the date of signing. I understand that I will not be refused treatment if I choose not to sign this authorization. I realize that the above stated medical facility cannot prevent the re-disclosure of records released as a result of this request and that the records may not be subject to the privacy rule protections. *

Please type your name in the above box to indicate that you have read and agree to the above authorization.

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Disclaimer

The information contained on this site is intended to provide only general education about foot & ankle surgery and conditions. It should NOT be regarded as diagnostic, treatment or any other type of specific medical advice to anyone. On this site, Dr. Silverman periodically provides assessments and commentary on specific procedures that individuals have undergone. These assessments do not indicate that Dr. Silverman has performed these specific surgeries. Individuals should always consult a licensed and qualified health care provider for evaluation, diagnosis and treatment recommendations regarding their specific medical problems. Results may vary from person to person.

Silverman Ankle & Foot

6600 France Ave S, #605
Edina, Minnesota 55435

Phone: 952.224.8500 Fax: 952.224.8515

View other locations here.

Minnesota Service Area

Dr. Silverman treats patients throughout Minnesota, including the cities of: Edina, Minneapolis, Apple Valley, Carver, Savage, St. Paul, Bloomington, Brooklyn Center, Chanhassen, Eden Prairie, Columbia Heights, Plymouth, Golden Valley, Hastings, Hopkins, Arden Hills, Lake Elmo, Maple Grove, Minnetonka, New Brighton, Richfield, Robbinsdale, Roseville, Shoreview, Wayzata, White Bear Lake, Woodbury, and more!

Dr. Lance Silverman
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