Authorization To Disclose Protected Health Information - Mayo Clinic - mayoclinic 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Release Information From' section. Select either 'Mayo Clinic (MCJ)' or specify another facility. Repeat this for the 'Disclose Information To' section.
3. In the 'Purpose of Disclosure' section, check the appropriate box indicating whether it's for continued care, personal reasons, or other purposes.
4. Specify the information to be disclosed by selecting relevant options such as 'HOSPITAL Abstract' or 'CLINIC Abstract', and include service dates if applicable.
5. Complete the identifying information fields including the patient's full name, social security number, address, date of birth, and phone number.
6. Review the authorization statement carefully before signing. Ensure you understand your rights regarding disclosure and expiration of this authorization.
7. Sign and date the form at the bottom. If someone else is signing on behalf of the patient, indicate their relationship.

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