Mayo Clinic Authorizations and Service Terms

The Mayo Clinic Authorizations and Service Terms form is presented to all patients seen at Mayo Clinic. The form authorizes Mayo Clinic to:

• Provide services and treatment or care coordination.
• Release records to insurance company(ies), when applicable. Some insurance plans require medical records before paying for services.
• Release information to those assigned to manage the patient's billing.
• Release records to accrediting and quality organizations, regulatory agencies, or other persons or entities for health care operations to ensure quality care is being delivered.
• Release records to share information with providers or staff involved with the patient's care.
• Release information to Mayo Clinic marketing individuals or affiliates who can provide the patient with information regarding available services and goods.
• Work with your insurance company(ies) to share past, current and future information strictly for the purposes of managing and coordinating your care or improving the quality of that care.
• Manage your health information exchange (HIE) status.
• Receive payment directly from insurers, when applicable.
• Send notifications using email, text or phone.

IMPORTANT NOTE: Language in the form, as presented, cannot be altered.

This form can be completed through the Patient Online Services site during the registration period only. This site allows you to complete your patient registration online, which includes electronic signature for the Mayo Clinic Authorization and Service Terms form. In addition, patients can view and pay their bills, view or request appointments, view records and results, refill or renew prescriptions, and message their clinical teams. In Florida and Minnesota, patients can also complete their Pre-Visit Questionnaire online.

• Go to www.MayoClinic.org/onlineservices and log in with your Patient Online Services user name and password. (If you forgot your user name or password, click "Need help logging in?"). Complete your patient registration under the billing and insurance section.
• If you do not have an account, click "Create your account" to create a new account and complete the online forms.

If you do not have email or access to set up an online patient account or cannot access the Authorization and Service Terms form on the site, you can download, print, review, sign and date the Mayo Clinic Authorizations and Service Terms form (PDF). Once the form is signed and dated, it should be faxed or dropped off at the Mayo Clinic location where you are receiving medical services, in the Registration department.

Arizona — Phoenix/Scottsdale

Fax: 480-301-8009

Questions: 507-284-3350

For Hospital Services Only: Please review, complete, sign and date the Conditions of Admission form (PDF). Fax the completed form to the number above. If you don't have a fax, please return the completed form to the admitting or registration department.

Florida — Jacksonville

Fax: 904-956-0010

Questions: 507-284-3350

For Hospital Services Only: Please review, complete, sign and date the Conditions of Admission form (PDF). Fax the completed form to the number above. If you don't have a fax, please return the completed form to the admitting or registration department.

Minnesota — Rochester

Fax: 507-266-4530

Questions: 507-284-3350