Medical Records Release

Please complete the form below or download the pdf and fax the document to 480-949-2091. DOWNLOAD PDF >>

- Patient's Full Name*
- Date of Birth*
  MM
  DD
  YYYY
- TO:
- Name (or title) and Organization
Address*
Street Address Address Line 2 City State ZIP Code
- Phone
- FAX
Email
Please disclose the following information (check all that apply):
- All of my health information including, but not limited to, AIDS/HIV and other communicable disease information, Behavioral Health Care/Psychiatric Care, Alcohol and/or Drug Abuse Treatment, unless specifically excepted,
- My health information relating only to the following treatment or condition:
Treatment or Condition (if checked above):
- My health information for the following date(s) of service:
Date(s) of service (if checked above)
- Other (specify)
If other, please specify:
You may disclose the health information to:
Name (or title) and Organization
Address of above organization*
Street Address Address Line 2 City State ZIP Code
- Phone
- FAX
Email
Consent*
Ok to fax medical records. (This document is confidential, intended for named recipient only.)
The signature below authorizes the release of my medical records as checked above. A copy of this signature form is as valid as original.
Signature
Date*
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.