In preparation of your appointment, you may be asked to complete some or all of the forms listed within the Pediatric or Adult sections below.
Note: All the forms below are posted in PDF file format. You will need the free Adobe Acrobat Reader software to view and print out these forms.
Medical Records Release Information and Release Form
Copies of medical records are available from Minnesota Epilepsy Group’s Medical Records Department. We take every precaution to protect the rights and privacy of our patients. To ensure the privacy of patients and their families and to comply with federal regulations, parents or guardians must sign an authorization form for releasing information. Processing of the request can take up to five working days or more.
Patient, parent and legal guardians have legal right to information about a patient’s care. Federal and state laws provide for the ability to obtain copies of medical records for a reasonable fee. Minnesota Epilepsy Group supports your legal rights and gives you access to the medical record free of charge.
Authorization to Release and Disclose Patient Information
Our Medical Records Department is open M-F 8:00a – 4:30p. Contact us by phone or mail.
Phone: (651) 377-8340
Fax: (651) 241-5248
Minnesota Epilepsy Group
Attn: Medical Records Department
2720 Fairview Avenue North.
Suite 100, Roseville, MN 55113
For New Pediatric Patients
Epilepsy is the tendency to have recurrent seizures. Using the most commonly used definition, having one seizure does not meet criteria for having epilepsy.
For New Adult Patients
For New Neuropsychology / Psychology Patients
For Self-Pay Patients
Additional Contact Info for Patient Portal
For Patients with a Court Appointed Guardian
Federal privacy laws require that we have proof of the current guardian/conservator’s identity in the patient medical record. we need you to send us a copy of the court order appointing you as the patient’s legal guardian/conservator. this ensures the patient’s privacty because it restricts who has access to his/her medical record.
Minnesota Driver Vehicle Services
Minnesota Epilepsy Group has also provided you with information on our privacy practices and collection policies for your review.
Find a map and directions on the Contact us page.