Authorization to Release Protected Health Information to a Third Party

Instructions: This form is to be used by a patient or legal representative to

authorize the release of information to a third party (other than a family member

or friend) such as an insurance company, employer, or for legal purposes, etc.

Print clearly; each section needs to be completed to be valid.

2. Additional Patient Information

Previous or Maiden Name (if applies) (First, Middle, Last) Daytime Phone

Check this

box if patient

is deceased.

Patient Address (Street, City, State, ZIP Code)

3. Release Purpose

Check appropriate box or write in other purpose.

Continuing care Disability Forms completion Insurance Legal Workers’ compensation

Other, specify ________________________________________________________________________________________________

4. Release Information FROM 5. Release/Send Information TO

Check one box and complete if applicable.

Mayo Clinic

Includes all Mayo Clinic and Mayo Clinic Health System locations

Other, specify organization, department, or individual (complete

each line below)

________________________________________________

Street ___________________________________________

City _____________________________________________

State ____________________ ZIP Code ________________

Phone ___________________________________________

Fax _____________________________________________

Check one box and complete each line for box checked.

Mayo Clinic

Dept. ____________________ Attn. ______________________

Fax ________________________________________________

Other, specify organization, department, or individual (complete

each line below)

__________________________________________________

Street _____________________________________________

City _______________________________________________

State _____________________ ZIP Code _________________

Phone _____________________________________________

Fax _______________________________________________

This authorization will expire in 1 year from date of signature unless another date is speciﬁed: _________________________________________

By checking this box I allow the ongoing exchange of information between the above parties until this authorization expires or is revoked.

By checking this box I also authorize the release of records for future visits or stays after the date of my signature until this authorization

expires or is revoked.

6. Delivery of Information

Preferred Method

Written copy (may include completed forms) Verbal only

Date Information Needed by

(mm-dd-yyyy)

Written information will be mailed unless an alternate method is checked.

Patient Portal – Mayo Clinic Patient Online Services

Fax (number listed above in section 5)

Email address ______________________________________________________________________________________________

Pick-up at a Mayo Clinic location, specify ___________________________________________________________________________

CD/DVD

USB ﬂash/thumb drive

Other, specify _______________________________________________________________________________________________

ENTERPRISE: Applies to Mayo Clinic locations in Arizona, Florida, Rochester and Mayo Clinic Health System.

MC0072-01rev0419

TO BE

SCANNED

Authorization to Release

Protected Health Information

to a Third Party

Form content retained in medical record.

Route to HIMS Scanning.

Staff Use Only

ROI to Send Records Scan to Chart

Information Released by

LAN ID

Date (mm-dd-yyyy)

(complete fields or place patient label here)

Patient Name (First, Middle, Last)

Birth Date (mm-dd-yyyy) Room Number (if applicable)

Mayo Clinic Number

Complete and print.

Reset Form

MC0072-01rev0419Page 2 of 2

7. Records or Reports to Be Released

Timeframe to Be Released

Date(s)___________________________________________________ or Year(s)____________________________________________

(mm-dd-yyyy) (yyyy)

Document/Note(s) (check all that apply)

Behavioral health/Mental/Psychological notes Emergency department/Urgent care notes

Operative/Procedure notes Provider notes

Therapy notes (physical, occupational, speech) Other, specify ____________________________________________________

I understand the information to be released may include behavior and/or mental health care, and HIV test results.

Additional Records (check all that apply)

Allergy list

Immunizations

Medication list

Laboratory results

HIV lab test results

Genetic testing

Pathology report(s)

EKG(s)/Cardio/Echo

Radiology report(s)

Radiology image(s), specify exam(s)/body part(s)

______________________________________

Billing information for records checked

Substance Abuse and Addiction Treatment Records (check all that apply)

Assessment/Evaluation

History and physical exam

Multidisciplinary notes

Family participation invitation

Questionnaires

Treatment/Discharge summary

Treatment plans

Other, specify

_______________________________

Other, specify if applicable __________________________________________________________________________________________

8. Signature and Date The patient or legal representative must sign and date this authorization.

• This authorization may be revoked at any time by providing a written notice of revocation to the Health Information Management Services (HIMS)

Release of Information (ROI) department at the facility releasing the information, except to the extent that the Providers have already taken action

in reliance on it.

• Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by

the Federal Privacy Law (42 CFR Part 2) (HIPAA).

• I understand that Mayo Clinic will not condition treatment on whether I sign this authorization.

• I may request a copy of the signed authorization.

• I may be charged for copies in accordance with state law.

• I have a right to inspect and receive a copy of the material to be disclosed.

Note: A patient (18 years or older) must authorize the release of their own information unless patient is incapacitated or deceased. If signing for a

minor patient, I hereby state that my parental rights have not been revoked by a court of law. Speciﬁc situation(s) may require minor’s authorization.

Signature (required)

Date (required)

(mm-dd-yyyy)

Printed Name of Person Signing (if not patient)

(First, Middle, Last)

Relationship if Not Patient (legal documentation of the right of access by the signing individual may be required)

Parent Stepparent Legal guardian Foster parent Health care power of attorney/agent Other___________________

HIMS

Release of Information Contact Information

Arizona

13400 East Shea Boulevard

Scottsdale, AZ 85259

Phone 480-301-4211

Fax 480-301-7282

Florida

4500 San Pablo Road

Jacksonville, FL 32224

Phone 904-953-2022

Fax 904-953-2242

Rochester

200 First Street SW

Rochester, MN 55905

Phone 507-284-4594

Fax 507-284-0161

MCHS MN

1025 Marsh Street

Mankato, MN 56001

Phone 507-594-2621

Fax 507-422-0902

MCHS WI

1400 Bellinger Street

Eau Claire, WI 54703-5211

Phone 715-838-6395

Fax 715-838-3058

Reminder: If sending records TO Mayo Clinic, fax records to number indicated in section 5 on page 1.

*Health Information Management Services

Authorization to Release

Protected Health Information

to a Third Party (continued)

(complete fields or place patient label here)

Patient Name (First, Middle, Last)

Birth Date (mm-dd-yyyy)

Mayo Clinic Number

Signature Required