Authorization To Disclose Protected Health Information Form

Download a blank fillable Authorization To Disclose Protected Health Information Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Authorization To Disclose Protected Health Information Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Health Information Management Services
Authorization To Disclose
Campus Support Center
4500 San Pablo Road
Protected Health
Jacksonville, Florida 32224
Reset
Information
(904) 953-2022
Return Fax (904) 953-2242
Print
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
-------------------------------------------------------------------------------------------
------------------------------------------------------
------------------------------------------------
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

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2