Medical Release to Send Report to Physician
› OPTIONAL: If you wish for Mayo Clinic Brain Bank to send a copy of the neuropathology report to the patient’ s neurologist or a different healthcare provider, complete this release and send it to the Mayo Clinic Brain Bank. Please note that the family will be receiving this report via mail and can choose to provide a copy of it to any provider as well as follow up with that provider to review the report.
› Please note that the Mayo Clinic Brain Bank is able to send the neuropathology report to only one medical provider. Additionally, Mayo Clinic is not responsible in the event that the provider’ s contact information is not correct or the provider is no longer at the listed institution.
By completing and signing this document, I give permission to the Mayo Clinic Brain Bank to release a copy of the neuropathology report of ____________________________________________________________( name of patient), ______________________( date of birth), to:
Name of doctor: ___________________________________________________________________________________________ Name of institution / hospital: ______________________________________________________________________________ Phone: ___________________________________________________ Fax: ____________________________________________ Address: ___________________________________________________________________________________________________ City: ______________________________________ State / Province: _____ ZIP code: ____________ Country: __________
Signature of patient or authorized patient representative: Circle one: patient, healthcare power of attorney, next of kin, or witness
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_______________________________________________________________________________________ Date: ________________
Contact information for healthcare power of attorney / next of kin: Name: _____________________________________________________________________________________________________ Relationship to patient: _____________________________________________________________________________________ Address: ___________________________________________________________________________________________________ City: ____________________________________ State / Province: ______ ZIP code: __________ Country: __________ Phone: ________________________________________________ Email: ______________________________________________