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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 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|\n\nRoute to HIMS Scanning.  \nInstructions: 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.  \n2. Additional Patient Information  \n1. (complete fields or place patient label here)  \nReset Form  \n\n| Patient Name (First, Middle, Last) |  |\n| --- | --- |\n| Birth Date (mm-dd-yyyy) | Room Number (if applicable) |\n| Mayo Clinic Number |  |\n\nStaff Use Only  \n\n|  ROI to Send Records  Scan to Chart |  |\n| --- | --- |\n|  Information Released by LAN ID | Date (mm-dd-yyyy) |\n\n\n| Previous or Maiden Name (if applies) (First, Middle, Last) | Daytime Phone |  Check this box if patient is deceased. |\n| --- | --- | --- |\n| Patient Address (Street, City, State, ZIP Code) |  |  |\n\n3. Release Purpose  \nCheck appropriate box or write in other purpose.  \n Continuing care  Disability  Forms completion  Insurance  Legal  Workers’ compensation  \n Other, specify    \n4. Release Information FROM 5. Release/Send Information TO  \nCheck one box and complete if applicable.  \n Mayo Clinic  \nIncludes all Mayo Clinic and Mayo Clinic Health System locations  Other, specify organization, department, or individual (complete  \neach line below)  \nStreet   City   State   ZIP Code   Phone   Fax    \nCheck one box and complete each line for box checked.  \n Mayo Clinic  \nDept   Attn   Fax    \n Other, specify organization, department, or individual (complete each line below)  \nStreet   City   State   ZIP Code   Phone   Fax    \n\n| This authorization will expire in 1 year from date of signature unless another date is specified:   |\n| --- |\n|  By checking this box I allow the ongoing exchange of information between the above parties until this authorization expires or is revoked.\u003Cbr> 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. |\n\n6. Delivery of Information  \n\n| Preferred Method\u003Cbr> Written copy (may include completed forms)  Verbal only | Date Information Needed by (mm-dd-yyyy) |\n| --- | --- |\n| Written information will be mailed unless an alternate method is checked.\u003Cbr> Patient Portal – Mayo Clinic Patient Online Services\u003Cbr> Fax (number listed above in section 5)\u003Cbr> Email address  \u003Cbr> Pick-up at a Mayo Clinic location, specify  \u003Cbr> CD/DVD\u003Cbr> USB flash/thumb drive\u003Cbr> Other, specify   |  |\n\nENTERPRISE: Applies to Mayo Clinic locations in Arizona, Florida, Rochester and Mayo Clinic Health System.  \n©2019 Mayo Foundation for Medical Education and Research Page 1 of 2  \nNext Page  \nMC0072-01rev0419  \nAuthorization to Release Protected Health Information to a Third Party (continued)  \n(complete fields or place patient label here)  \n\n| Patient Name (First, Middle, Last) |\n| --- |\n| Birth Date (mm-dd-yyyy) |\n| Mayo Clinic Number |\n\n7. Records or Reports to Be Released  \n\n| Timeframe to Be Released\u003Cbr>Date(s)  or Year(s) \u003Cbr>(mm-dd-yyyy) (yyyy) |  |\n| --- | --- |\n| Document/Note(s) (check all that apply)\u003Cbr> Behavioral health/Mental/Psychological notes  Emergency department/Urgent care notes\u003Cbr> Operative/Procedure notes  Provider notes\u003Cbr> Therapy notes (physical, occupational, speech)  Other, specify  \u003Cbr>I understand the information to be released may include behavior and/or mental health care, and HIV test results. |  |\n| Additional Records (check all that apply)\u003Cbr> Allergy list  Laboratory results  Pathology report(s)\u003Cbr> Immunizations  HIV lab test results  EKG(s)/Cardio/Echo\u003Cbr> Medication list  Genetic testing  Radiology report(s)\u003Cbr> Billing information for records checked |  Radiology image(s), specify exam(s)/body part(s) |\n| Substance Abuse and A","cbCaiksBLaA6XDTT","https://ap.wps.com/l/cbCaiksBLaA6XDTT","pdf",169042,"English","# Authorization to Release Protected Health Information to a Third Party\n## Patient and staff use sections\n## Release purpose and information routing\n## Records to be released\n## Signature, expiration, and delivery methods","[{\"question\":\"Who can use this authorization form?\",\"answer\":\"The form is used by a patient or a legal representative to authorize release of information to a third party.\"},{\"question\":\"How long is the authorization valid?\",\"answer\":\"It expires in 1 year from the date of the signature unless another date is specified.\"},{\"question\":\"What kinds of records can be released?\",\"answer\":\"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.\"}]","Authorization to Release Protected Health Information to a Third Party - MC0072-01 - Form | PDF",1789617259]