Authorization to Release Protected Health Information

1.
Authorization to Release
Protected Health Information
Name (First, Middle, Last) Previous/Maiden Name Birth Date (Month DD, YYYY) MRN
Mailing Address of Patient - Street
City State ZIP code Phone
2.
4.
Instructions: If any section is incomplete, this form may be invalid and the request cannot be processed.
Release Information From
3. Release Information To
Mayo Clinic Health System, 1000 First Drive N.W., Austin, MN 55912
Addiction Recovery Services, 101 14th St. N.W., Austin, MN 55912
Mayo Clinic Health System, 1000 First Drive N.W., Austin, MN 55912
Addiction Recovery Services, 101 14th St. N.W., Austin, MN 55912
Other – Facility/Name
Other – Facility/Name
Street Address
Street Address
City State ZIP Code
City State ZIP Code
Fax
Phone
Fax
Phone
Purpose of Release
Treatment/Continued Care Personal Legal Purposes
Application for Insurance Disability Determination Payment of Insurance Claim
Other
5.
6.
7.
8.
Information to be Released
Service Dates (approximate) Copies Verbal Exchange of Information (No Copies)
Review of my Medical Record
History and Physical EKG’s Laboratory Reports
Immunization Records Pathology Reports Radiology Reports
Clinic Notes Operative Reports Radiology Images
Other
Hospital Notes
Hospital Discharge Summary
Billing Statements
I extend to release any or all documents in upcoming year
I understand the information to be released may include records related to behavioral and/or mental health care, alcohol and drug abuse
treatment, HIV/AIDS, and genetics.
This authorization may be revoked at any time except to the extent that action has been taken in reliance upon it. Revocation must be made
in writing to the provider/facility releasing the information. I may be charged for copies in accordance with state law. The provider/facility will
not condition treatment on whether I sign the authorization. Information used or disclosed pursuant to this authorization may be subject to
redisclosure by the recipient and may no longer be protected by federal law.
This authorization will expire one year from the date of signing unless I indicate an earlier date or event here: ___________________________.
ATTENTION: This is a legal document. Please read carefully. By signing, you agree that you understand and accept the terms on this form.
• If the patient is 18 years of age or older, the patient must sign and date the form.
• If the patient is 18 years of age or older and is incapable of signing, a legally authorized substitute may sign and date the form.
Please indicate your legal authority and include documentation of your relationship:
Legal Guardian or Conservator Health Care Agent (Health Care Power of Attorney)
• If the patient is 17 years of age or younger, the patient’s parent or legal guardian must sign and date the form, unless an exception
exists under state or federal law. Please indicate your relationship:
Parent
Signature (Required)
Legal Guardian
Addiction Recovery Service Records
Psychiatry & Psychology Records
Date Signed (Required) (Month DD, YYYY)
Printed Name of Person Signing (If Not Patient)
Witness Signature
FOR INTERNAL USE ONLY Needed By Sent to ROI _____ Radiology _____
©2013 Mayo Foundation for Medical Education and Research 006664rev0613

Release of Information Instructions
Albert Lea and Austin
Austin
Authorization Completion Instructions
To protect the privacy of our patients and to maintain the confidentiality of their personal health information, we must obtain a valid, complete,
and legible authorization for release of medical records.
1. Patient:
• Name: Print the full, legal name of the patient
• Previous/Maiden Name: Any previous legal names
• Birth Date: Month, Day, and Year of birth
• Mailing Address of Patient: Street, City, State, and Zip Code of Patient
• Phone: Patient’s phone number
2. Release Information From:
• Check the sites listed where you have received care and who you want to allow to release your medical information.
• If the provider authorized to release information is other than Mayo Clinic Health System – Austin, check the Other box and
complete the Individual, Facility or Company Name of that person or Provider. Fill in their complete address. Include their phone
number if known.
3. Release Information To:
• Print the name of the person or organization that is to receive the information, along with their complete address, city, state,
and zip code. Please include their phone number if known.
4. Purpose of Release:
• Check the appropriate box that best explains the purpose of the request.
• If the Other box is checked, please write the reason in the space provided.
5. Information to be Released:
• Fill in the approximate dates of service if known.
• Check the appropriate box if copies, a verbal exchange, or a review of the medical record is requested.
• Check the box next to the types of information requested.
• If the other box is checked, please write the needed information in the space provided.
6. I extend to release any or all documents in the upcoming year:
• Check this box to authorize medical information that is created after the date of signature on this form to be released. If this box
is not checked, we are only able to release medical information that was created on or before the date this authorization was signed.
7. Expiration Date:
• This authorization will be valid for one year unless otherwise specified by a date written in this area. Do not write today’s date
as the expiration date or the request will not be able to be processed.
8. Signature:
• The patient or legal representative must sign and date the authorization.
• Attach copies of documents outlining the representative’s legal right to sign on the patient’s behalf.
If records are needed to be released from Mayo Clinic Health System – Austin, please return the completed authorization by one of the
following methods:
FAX | 507-434-1447 IN PERSON | Health Information Management/ MAIL | Mayo Clinic Health System
Release of Information
Attention: Release of Information
1000 First Drive N.W.
Austin, MN 55912
If records are needed from a facility other than Mayo Clinic Health System – Albert Lea and Austin, the completed authorization should be forwarded
directly to that facility. If assistance is needed with completing this form, contact the Health Information Management Department at 507-434-1132
during the hours of 8 a.m. to 5 p.m., Monday through Friday.
©2013 Mayo Foundation for Medical Education and Research 006664rev0513