Authorization To Disclose Protected Health Information with Map

Health Information Management Services

Campus Support Center

4500 San Pablo Road

Jacksonville, Florida 32224

(904) 953-2022

Return Fax (904) 953-2242

PLEASE PRINT

Authorization To Disclose

Protected Health Information

RELEASE INFORMATION FROM DISCLOSE INFORMATION TO

□ Mayo Clinic (MCJ) □ Other (Specify Facility/Address) □ Mayo Clinic (MCJ)

Health Information Management Services

□ Pharmacy □ Other (Specify Facility/Address)

____________________________________________________ ____________________________________________________

PURPOSE OF DISCLOSURE

□

Continued Care (abstract* will be provided, unless otherwise specified)

□

Personal - I understand that I may be charged for copies of this information in

accordance with Florida Law.

□

Other_____________________________________________________________________

INFORMATION TO BE DISCLOSED (Specify service dates ____________________________________________________)

□

HOSPITAL Abstract (includes, as applicable, Discharge Summary, Discharge Medication List, History & Physical,

Operative/Procedure Report(s), ED Report(s), Consultation Report(s), and test result(s)

□

CLINIC Abstract (includes, as applicable, most recent Return Visit, History & Physical, Consultation Report(s), Summary

Lists, and test result(s)

□

Other__________________________________________________________________________________________________

IDENTIFYING INFORMATION AT THE TIME OF SERVICE

_____________________________________________ ______________________________________________

Patient’s Full Name Patient’s Social Security Number/Medical Record Number

__________________________________________________ ___________________________________________________

Address Patient’s Date of Birth

__________________________________________________ ___________________________________________________

City/State/Zip Patient’s Phone Number

I understand that disclosure of the information in this medical record may include information relating to sexually transmitted disease,

acquir

ed immunodeficiency syndr

ome (AIDS), or human immunodeficiency vir

us (HIV). It may also include information relating to

behavioral or mental health services or treatment, treatment for substance abuse, or genetic test results.

I understand that this authorization will expir

e in one year fr

om the date signed below unless otherwise specified_________________ .

I understand that once the information is disclosed, the information is subject to r

edisclosure and may no longer be protected by the federal

privacy r

egulations. This form may be r

evoked at any time pr

oviding the information has not alr

eady been disclosed. I may r

evoke this

authorization by notifying, in writing, the Health Information Management Supervisor, 4500 San Pablo Road, Campus Support Center,

Jacksonville, FL

32224.

I understand that Mayo will not condition treatment, payment, enrollment or eligibility for benefits on my signing this authorization.

I understand the matters discussed on this form. I r

elease the pr

ovider

, its employees, of

ficers and dir

ectors, medical staff members, and

business associates from any legal responsibility or liability for the disclosure of the above information to the extent indicated and authorized

her

ein.

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Signature of Patient or Patient’s Representative* Relationship (if not patient) Date

*If a personal representative of the patient signs the authorization, please indicate his or her authority to act.

Official Use Only

Received ___________________________________

Provided___________________________________

Processed by _______________________________

Log # ______________________________________

# of Pages_________

□ Mail

□ Pick-up

□ Other

□ Entire MR

□ Abstract

□ Other

_________

Date Loan Loan Initial

Completed

ROIAD

Unique

MCJ255/R408