Patient Forms
For referring providers:
Blue Ribbon Dermatology Provider Referral Form
Grant access to your protected health information
If you're a Blue Ribbon 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.
Medical Records Request Form
Patient Information Forms
Gentle Skin Care
Quick, easy tips to keep your skin healthy and protected.
Sun Protection
Simple tips to keep your skin safe from UV damage
Vinegar Soaks
(use only if directed)
(use only if directed)
Vinegar Soak guide for wound care to help prevent infection and promote healing
HIPAA Notice of Privacy Practices (NPP)
Understand your rights and how your information is shared
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.
Arabic: التخويل باإلفصاح عن بيانات صحية
English: Authorization to Release Protected Health Information to a Third Party(PDF)
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
If you still have questions regarding accepted insurance types or your insurance coverage, contact Patient Account Services for additional support.
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
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.
