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Authorization to Disclose Protected Health In - MCS7602 - Mayo Clinic 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the patient's name, date of birth, and address in the designated fields. Ensure accuracy as this information is crucial for identification.
- Input the Mayo Clinic Medical Record Number and daytime telephone number. This helps facilitate communication regarding the request.
- Select how you would like the information disclosed: via mail, pick-up, or clinic/hospital. Fill in the name of the person or entity receiving the information and their address.
- Indicate the purpose for releasing this information by checking one of the options provided: Personal, Continuing Patient Care, or Other.
- Specify what information is being requested. If not completed, a records abstract will be provided covering two years of recent records.
- If billing statements are needed, check 'Yes'.
- Sign and date at the bottom of the form. If you are not the patient, include your relationship to them.
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