Health Information Management Services
Authorization To Disclose
Campus Support Center
4500 San Pablo Road
Protected Health
Jacksonville, Florida 32224
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Information
(904) 953-2022
Return Fax (904) 953-2242
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Please complete, print, sign, and submit.
PLEASE PRINT
RELEASE INFORMATION FROM
DISCLOSE INFORMATION TO
Mayo Clinic in Florida (MCF)
Other Mayo Site (Please Specify)
MCF Health Information Management Services
Pharmacy
Other (Specify Facility/Address)
Other (
)
Specify Facility/Individual/Address/Relationship, as applicable
________________________________________________________________
_______________________________________________
________________________________________________________________
_______________________________________________
PURPOSE OF DISCLOSURE
Continued Care (abstract* will be provided, unless otherwise specified)
Personal - I understand that I may be charged for copies of this information in
accordance with applicable state law.
Other _____________________________________________________________________
INFORMATION TO BE DISCLOSED (Specify service dates ____________________________________________________)
HOSPITAL Abstract (includes, as applicable, Discharge Summary, Discharge Medication List, History & Physical,
Operative/Procedure Report(s), ED Report(s), Consultation Report(s), and test result(s)
CLINIC Abstract (includes, as applicable, most recent Return Visit, History & Physical, Consultation Report(s), Summary
Lists, and test result(s)
Other__________________________________________________________________________________________________
IDENTIFYING INFORMATION AT THE TIME OF SERVICE
_____________________________________________
______________________________________________
Patient’s Full Name
Medical Record Number/Last 4 digits of Patient’s
Social Security Number
__________________________________________________
___________________________________________________
Address
Patient’s Date of Birth
__________________________________________________
___________________________________________________
City/State/Zip
Patient’s Phone Number
I understand that disclosure of the information in this medical record may include information relating to sexually transmitted disease,
acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information relating to behavioral
or mental health services or treatment, treatment for substance abuse, or genetic test results.
I understand that this authorization will expire in one year from the date signed unless otherwise specified:_______________________________ .
I understand that once the information is disclosed, the information is subject to redisclosure and may no longer be protected by the federal
privacy regulations. This form may be revoked at any time providing the information has not already been disclosed. I may revoke this
authorization by notifying, in writing, the Health Information Management Supervisor, 4500 San Pablo Road, Campus Support Center,
Jacksonville, FL 32224.
I understand that Mayo will not condition treatment, payment, enrollment or eligibility for benefits on my signing this authorization.
I understand the matters discussed on this form. I release the provider, its employees, officers and directors, medical staff members, and
business associates from any legal responsibility or liability for the disclosure of the above information to the extent indicated and authorized
herein.
______ My initials on this line indicate I am authorizing the person(s) listed in the “Disclose Information To” box above to also have access to
my Patient Portal upon request by that person. I understand that my authorization grants this person access to my past, present and future
protected health information. Access to my Patient Portal will not expire until such time that I revoke access in writing.
x
Signature Required
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Signature of Patient or Patient’s Representative*
Relationship (if not patient)
Date
*If a personal representative of the patient signs the authorization, please indicate his or her authority to act.
Official Use Only
Date Loan
Loan Initial
Completed
# of Pages_________
Provided ___________________________________
Mail
Pick-up
Unique
Processed by _______________________________
Other
Entire MR
Log # ______________________________________
Abstract
Other _________
MCJ0255rev0814