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Medical Record Forms

If you're a Mayo Clinic Health System patient or have been one in the past, you can use these forms to grant permission for others to access your protected health information or request a change to your health record. 

Grant access to your protected health information

Complete and submit the appropriate authorization form below:

Authorize the release of information

The Authorization to Release Protected Health Information to a Third Party form is used to authorize the release of health information for insurance, employment, legal or corporate health purposes. It's used by patients to transfer records from another healthcare facility to Mayo Clinic Health System.

Authorize the release of substance abuse and addiction treatment information

Prior to releasing patient information to another facility, the patient will be asked to complete and sign the Authorization to Release Substance Abuse and Addiction Treatment Information form (PDF). This form authorizes the substance abuse and addiction treatment programs at Mayo Clinic Health System to disclose to, and receive from, the insurer information related to the patient’s treatment for the purposes of receiving payment for healthcare services and the insurer’s healthcare operations.

Amend or change your health record

If you believe that a change needs to be made to your medical records, follow the instructions in the Medical Record Information for an Amendment Request (Spanish Version) and use the Request for Amendment of Health Information (Spanish Version) to submit.

You can submit a request using the following email or mailing address:

Email: HIMSAMENDMENTREQ@mayo.edu

Mailing address:
Health Information Management Services
Attn: Amendment Request Specialist
Mayo Clinic
Campus Support Center
4500 San Pablo Road
Jacksonville, FL 32224

If you have questions about the process for requesting a change to your medical records, call 507-538-7700 and select option 1.

Authorize to treat unaccompanied minor

Complete this form to give Mayo Clinic Health System permission to treat a minor if a parent or legal decision maker cannot be present prior to treatment.

FAQ

How do I notify Mayo Clinic of an adoption?

To notify Mayo Clinic of an adoption, provide a copy of one of the following required legal documents:

  • Adoption Decree/Decree of Adoption.
  • Order on Petition for Adoption.
  • Finding and Order for Judgment and Decree of Adoption.

The following documentation is not acceptable:

  • A birth certificate.
  • Certificate/Application of Adoption.
  • Notice of case filing.
  • A document signed by the Clerk of Court.
  • Petition for Adoption.
  • Termination of Parental Rights.
  • Custody.
  • Guardianship.

You may provide the required document in one of two ways:

  • Adoptive parents can provide a copy of the required legal document in its entirety to the Registration desk at your Mayo Clinic location and ask that a copy be emailed to the Health Information Management Services (HIMS) Data Integrity Team.
  • Adoptive parents can email a copy of the required legal document in its entirety to PATRECUPDREQ@mayo.edu or send by mail to the following address:

Mayo Clinic
Health Information Management Services
Attn: HIMS Data Integrity
Campus Support Center
4500 San Pablo Road
Jacksonville, FL 32224

Read answers to other frequently asked questions about adoption records.