Authorization to Release Protected Health Information to a Third Party - MC0072-01 - Form

Sep 17, 2026

Authorization form for patients or legal representatives to permit disclosure of protected health information to a third party (not a family member or friend) for purposes such as insurance, employment, continuing care, disability, legal matters, or workers’ compensation. Includes sections to enter patient identifiers, release purpose, information source and recipient (including Mayo Clinic location details), expiration rules, delivery method preferences, timeframe and categories of records to release, and signature and date requirements.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Authorization to Release Protected Health Information to a Third Party

Patient and staff use sections

Release purpose and information routing

Records to be released

Signature, expiration, and delivery methods

Complete and print. Authorization to Release Protected Health Information to a Third Party Form content retained in medical record. | TO BE | | --- | | SCANNED | Route to HIMS Scanning. 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 1. (complete fields or place patient label here) Reset Form | Patient Name (First, Middle, Last) | | | --- | --- | | Birth Date (mm-dd-yyyy) | Room Number (if applicable) | | Mayo Clinic Number | | Staff Use Only | ROI to Send Records Scan to Chart | | | --- | --- | | Information Released by LAN ID | Date (mm-dd-yyyy) | | 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. ©2019 Mayo Foundation for Medical Education and Research Page 1 of 2 Next Page MC0072-01rev0419 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 | 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 Laboratory results Pathology report(s)
Immunizations HIV lab test results EKG(s)/Cardio/Echo
Medication list Genetic testing Radiology report(s)
Billing information for records checked | Radiology image(s), specify exam(s)/body part(s) | | Substance Abuse and A

FAQs

Who can use this authorization form?

The form is used by a patient or a legal representative to authorize release of information to a third party.

How long is the authorization valid?

It expires in 1 year from the date of the signature unless another date is specified.

What kinds of records can be released?

Selected document categories may include behavioral health/mental health notes, emergency/urgent care notes, operative/procedure notes, provider and therapy notes, and additional records such as lab results, immunizations, radiology reports/images, billing information, and substance abuse treatment records.

Sep 17, 2026

Uploaded by Nguyễn Văn Học