Health Information Management Services Campus Support Center 4500 San Pablo Road Jacksonville, Florida 32224 Authorization To Disclose (904) 953-2022 Return Fax (904) 953-2242 Protected Health Information PLEASE PRINT RELEASE INFORMATION FROM DISCLOSE INFORMATION TO □ Mayo Clinic (MCJ) □ Other (Specify Facility/Address) □ Mayo Clinic (MCJ) Health Information Management Services □ Pharmacy □ Other (Specify Facility/Address) ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ 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 Florida 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 Patient’s Social Security Number/Medical Record 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 below 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. -------------------------------------------------------------------------------------------x ------------------------------------------------------ ------------------------------------------------ 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 Received ___________________________________ # of Pages_________ □ Mail ROIAD Provided___________________________________ □ Pick-up Unique □ Other Processed by _______________________________ □ Entire MR □ Abstract □ Other _________ Log # ______________________________________ MCJ255/R408 W. M. Davis Parkway e e v i v r i r D y D a h a g w Lot E-2 l Lot i k l r r Lot E-1 i a t B P i E-8G s y i m v The Inn at r Lot o a a ED d D D e M . a v Mayo Clinic i E-1G M CUP entrance o . Future r R W B D o Lot h Stabile Mayo l s b i l a E-3 l Valet Lot D e North Building P M Cannaday n and Lot a CUP Bldg. S Stabile Hospital C A Lot E-2 South Hospital Drive W o ive r Dr ra ro Sculpture ll Map not drawn b Lot E-4G Garage W Zum Garden ay to scale Davis Lot B Campus Building Louchery Support Island Campus Center Lot E-4 Main (CSC) Lot E-4 Birdsall Plaza Entry W o Griffin IS rr Lake Mayo Blvd. C g a Ke Lot A M l n o in l d Mayo t d W a uil ll Hench Circle B a y Lot E-7 Courtyard d a by Marriott o Lot E-6 Valet R o l b a P n a S N.E. Florida Hospice.