Authorization to Release
Protected Health Information
to a Third Party

Form content retained in medical record.
Route to HIMS Scanning.
TO BE
SCANNED
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.
1.        (complete fields or place patient label here)  
 Patient Name (First, Middle, Last)
 
 
Birth Date (mm-dd-yyyy) 
 
 
Staff Use Only
 
 Information Released by LAN ID Date (mm-dd-yyyy) 
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.
 
 
 
4. Release Information FROM      5. Release/Send Information TO
Check one box and complete if applicable.

Includes all Mayo Clinic and Mayo Clinic Health System locations






​​​​​​
 specify organization, department, or individual (complete
 each line below) 
Street 
Check one box and complete each line for box checked.
 
specify organization, department, or individual (complete
 each line below) 
Street 
 
This authorization will expire in 1 year from date of signature unless another date is specified: 
 I allow the ongoing exchange of information between the above parties until this authorization expires or is revoked.
 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
 		 Date Information Needed by (mm-dd-yyyy) 
Written information will be mailed unless an alternate method is checked.
 
 7. Records or Reports to Be Released
Timeframe to Be Released
 Date(s) 
or Year(s)
Document/Note(s) (check all that apply)
 
 
 
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)
 
 
Substance Abuse and Addiction Treatment Records (check all that apply)
 
 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)

Clear Signature

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