Medical Release to Send Notes to Mayo Clinic
› In addition to sending a copy to the Mayo Clinic Brank Bank, this form should be sent to the doctor who diagnosed or primarily managed the patient’ s neurological diagnosis and who is listed on the questionnaire. Please ask that they send all current and previous records to the Mayo Clinic Brain Bank as soon as they can.
› Please ask them to keep this form on file in the patient’ s medical records to refer to if needed. › At the time of the patient’ s passing and brain donation, please contact the provider’ s office and ask them to send any new recent visits since the original request was made with relevant neurology notes to the contact information below.
By completing and signing this document, I give permission to _________________________________________( name of doctor and institution / hospital) to release a copy of the medical reports and / or records of __________________________________________________________( name of patient), _________________( date of birth), to the Mayo Clinic Brain Bank in Jacksonville, Florida.
Signature of patient or authorized patient representative: Circle one: patient, healthcare power of attorney, next of kin, or witness __________________________________________________________________________________ Date: ________________
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Contact information of patient’ s healthcare power of attorney / next of kin: Name: _______________________________________________________________________________________________ Relationship to patient: ______________________________________________________________________________ Address: _____________________________________________________________________________________________ City: _______________________________________ State / Province: ____ ZIP code: __________ Country: ________ Phone: ____________________________________________ Email: ____________________________________________
Note to medical center: Please include history, medical and neurological evaluation, diagnosis, CT or MRI scans, other X-ray reports, electroencephalogram report, medication history, electrocardiogram report, and any other data pertinent to the neurodegenerative diagnosis. These notes are used with the results of the brain tissue analysis and diagnosis. All information will be held in the strictest confidence.
Please have all neurology records sent to:
Rachel LaPaille-Harwood Mayo Clinic Neuropathology Program Coordinator 4500 San Pablo Road Birdsall Building, Room 310 Jacksonville, FL 32224 Email: lapaille-harwood. rachel @ mayo. edu Phone: 904-953-2439 Fax: 904-953-7117