Authorization Form

Signing the authorization form allows Mayo Clinic to do the following:

  • Provide you with medical treatment
  • Release your medical information to other parties as necessary for treatment and payment of services
  • Receive payment from third parties (such as insurance companies) for your care

A form will need to be signed for each person receiving care, regardless of age. If the patient is 17 or under a parent or legal guardian must sign. Please see the form for complete details. 

Download the Mayo Clinic Authorizations and Service Terms form (PDF file)

Please bring the completed form to your first appointment. You may bring completed forms for other family members at the same time. They will be added to the medical record for each.