Patient 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
Authorization to discuss medical information with others

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

By mail:

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.

• Pediatric New Patient History Form
• Consent and Payment Authorization Form

For New Patients

• Adult New Patient History Form
• Consent and Payment Authorization Form
• Pediatric New Patient History Form

Additional Patient Forms and Policies

• Additional Contact Info
• Billing and Collection Policy
• Notice of Privacy Practice

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

• Seizure/Loss of Conciousness Waiver

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.