MDA Patient Authorization Forms

Welcome to the MD Anderson Patient Authorization Portal Powered by eHealth Technologies

Please select the appropriate form, or if you do not know which form to fill out please contact customer service at 877-344-8999 (Option 4)

English Language Release Form
Spanish Language Release Form

Authorization Forms Library
Please use one of the following forms if your patient access team has requested a specific provider form to be completed.
The required form will need to be printed, completed, and faxed to the Patient Intake Group (866.443.7618)

CDX New York
Mayo Clinic
Medical Center of Plano Pathology
Medical Diagnostic Pathology
Methodist Dallas Medical
Mike O’Callaghan Military
Mount Sinai
NY Presbyterian
NY Presbyterian Columbia and Cornell
NYU Hospital Center
Ohio State University Hospital
Seidman Cancer Center
Thomas Jefferson
Toronto General Hospital
UPMC Pathology
UPMC Medical Records and Radiology
Westchester