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.
©2019 Mayo Foundation for Medical Education and Research Page 1 of 2
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
1.