ARIZONA COMMUNITY PHYSICIANS, P.C.
AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION
PATIENT INFORMATION
Patient Name_________________________________________ Account #_____________________
Former Name (If any)________________________________________________________________
Daytime Telephone____________________________________ Birth Date_____________________
INFORMATION TO BE RELEASED FROM
I hereby authorize (name of organization)_________________________________________________
To release the following medical information contained in patient’s medical record.
INFORMATION TO BE RELEASED TO
Name of Physician/Organization _____________________________________________________
Street Address ____________________________________________________________________
City/State/Zip_____________________________________________________________________
Phone # _________________________________________________________________________
PURPOSE FOR THE REQUEST
(Please check a box)
Moving
Treatment or consultation
Dissatisfaction
Change of Insurance Plans
At patients request
ٱ
Other (specify) _____________________________________________________________________
TYPE OF INFORMATION TO BE RELEASED
(No information will be released unless a box is checked)
DATES OF TREATMENT
General Release
Medical Records/Excluding Protected Records
From________ To_______
(This will be limited to 1 year of information including Lab, x-ray reports
unless otherwise stated)
Other Records (specify) ________________________________
From________
To________
Information Protected by State/Federal Law
All of my records including:
From_______ To________
AIDS/HIV and Other Communicable Disease Information,
Behavioral Health Care/Psychiatric Care, Alcohol and/or Drug Abuse Treatment
THIS AUTHORIZATION WILL AUTOMATICALLY EXPIRE AFTER ONE YEAR (or 60
days for drug and
alcohol abuse records) from the date of signing. The undersigned may revoke this authorization at any time by providing written
notice of revocation.
With respect to drug and alcohol abuse treatment, information or records regarding communicable disease-related information, the
recipient of this information understands that it is prohibited from making any disclosure of this information unless further
disclosure is expressly permitted by written consent of the undersigned or otherwise permitted by applicable law.
Signature of Patient or Personal Representative Who May request Disclosure
I understand that Arizona Community Physicians may not condition my treatment on whether I sign this authorization form unless
specified above under Purpose for Request. I can inspect or receive a copy of the protected health information to be used or
disclosed. I authorize Arizona Community Physicians to use and disclose the protected health information specified above
_______________________________________
__________
__________________________________
Signature of Patient OR Legal Representative
Date
Please Print Name of signing party
Patient Requesting Medical Record Copies
The charge for copying medical records from a paper chart will be $0.50 a page.
For offices using our Electronic Health Record system, patients may request a
copy of their chart on a “CD” for $10.00
FORM # 100