Authorization to Disclose Protected Health In - MCS7602 - Mayo Clinic 2026

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. Input the Mayo Clinic Medical Record Number and daytime telephone number. This helps facilitate communication regarding the request.
4. 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.
5. Indicate the purpose for releasing this information by checking one of the options provided: Personal, Continuing Patient Care, or Other.
6. Specify what information is being requested. If not completed, a records abstract will be provided covering two years of recent records.
7. If billing statements are needed, check 'Yes'.
8. Sign and date at the bottom of the form. If you are not the patient, include your relationship to them.

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