Upper Midwest Health Information Request Form
Purpose. The Upper Midwest Health Information Request Form can be used in connection with the Upper
Midwest Consent Matrix and Upper Midwest Common Consent Form for Full Disclosure to enable the exchange of
consent and the disclosure of health information among the Upper Midwest States (Illinois, Minnesota, North
Dakota, South Dakota, and Wisconsin) for treatment, payment, and health care operation purposes.
Instructions. To request disclosure of health information from an Upper Midwest State:
(1) use the Upper Midwest Consent Matrix to determine if the disclosure triggers a requirement for patient
consent;
(2) request that the patient complete the Upper Midwest Common Consent Form (if consent is required);
(3) complete the Health Information Request Form below; and
(4) use the Direct Project Health Information Exchange Protocol (Direct Protocol) to transmit the Health
Information Request Form, along with the patient-completed Upper Midwest Common Consent Form (if
needed), by attaching images of the documents and sending them the to disclosing provider via direct
message.
Requesting Provider Information
Person/Organization Name: ______________________________________ Phone: (_____)________________
Address: ______________________________________________________Fax: (______)__________________
Email Address: ______________________@___________________________
Patient Information
Name (First Middle Last): ______________________________________________________________________
Gender: M F
Date of Birth (mm/dd/yyyy): __________/__________/__________________
Address: ___________________________________________________
City: _______________________State: ____________Zip:___________
Patient Information Requested
Continuity of Care Document (CCD), consisting of the following kinds of information:
 Problems
 Immunizations
 Procedures
 Medical equipment
 Family history
 Vital signs
 Social history
 Functional stats
 Payers
 Results
 Advance directives
 Encounters
 Alerts
 Plan of care
 Medications

Other: ___________________________________________________________
Upper Midwest Health Information Request Form
1
Page 1 of 1
Revised: September 20, 2011