For Patients & Visitors
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:
- English adult: Authorization to Disclose Protected Health Information to Family and Friends Adult Patient
- English child: Authorization to Disclose Protected Health Information to Family and Friends Minor Child
- Spanish adult: Autorización para revelar información médica confidencial a familiares y amigos Paciente adulto
- Spanish child: Autorización para revelar información médica confidencial a familiares y amigos Menor de edad
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 health care facility to Mayo Clinic Health System.
- Arabic: التخويل باإلفصاح عن بيانات صحية
- English: Authorization to Release Protected Health Information to a Third Party
- Hmong: Kev Tso Cai rau Tso Tawm Cov Ntaub Ntawv Fab Kev Kho Mob Uas Raug Tiv Thaiv mus rau Tog Neeg Thib Peb
- Somali: Oggolaanshaha in Loo shaaciyo Macluumaadka Ilaashan ee caafimaadka Kooxda saddexaad
- Spanish: Autorización para revelar información médica confidencial a un tercero
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. 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 health care services and the insurer’s health care operations.
Amend or change your health record
Follow these instructions on how to request a change or amendment to your health record if you believe it's inaccurate or incomplete.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.