Prairie St. John's Hospital fax number

Fax destination details

Department

Health Information Management – Release of Information Team

Purpose

Medical records release / Release of Protected Health Information (PHI) via ROI fax

Form

Authorization for Exchange of Protected Health Information (RM.204.F03a) — Authorization for Exchange of Protected Health Information RM.204.F03a

Address

510 4th St S, Fargo, ND 58103

Voice phone

701-476-7200

Website

Visit organization website

Before you send

• Confirm that this exact department handles your document or request.
• Check the organization website or call its main line for the current fax number.
• Include a cover sheet and any case, member, claim, or form reference required.
• Keep the delivery confirmation with your submission records.

Fill patient info (name, DOB, contact). Specify recipient organization and fax. Indicate treatment dates to exchange. Mark the PHI to be exchanged (e.g., Lab Results, Discharge Summary, Substance Use Evaluation). State purpose (care coordination, legal, insurance). Sign and date; expiration up to 12 months. Minors have special signature requirements per policy. A photocopy or fax is treated as the original.

Official form instructions are published as a downloadable file on the organization's website.