Authorization for disclosure of medical information

The authorization for disclosure of medical information form needs to be filled out if you would like a copy of your medical record or if you want to release your medical record to a provider outside of Medcenter One.

Click here for complete instructions for the disclosure of medical information.

Click here to fill out the form electronically. Then print and sign the disclosure of information form.

Or, click here to print the form and handwrite your information.

Then, send the completed and signed form to:
Medcenter One
300 N. Seventh St.
Bismarck, N.D. 58501

Or fax it to:
Clinic medical records—701.323.5695
Hospital medical records—701.323.6951