Phone: (480) 443-8400 Fax: (480) 443-8697 Authorization ...

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ARIZONA ARTHRITIS & RHEUMATOLOGY ASSOCIATES, Phone: (480) 443-8400 Fax: (480) 443-8697 . Authorization for Disclosure of protected Health Information Patient Information: (please print). Patient Full Name: _________________________ Other Names Used?___________________. Patient Address: ________________________________________ __ Date of Birth:_______. City:______________________State:_______ Zip: ____________ Phone: _________________. Release Information From: (please print). Name/Facility: ________________________________________ Attention: ______________. Address: ________________________________________ _____ Fax: ___________________. City:______________________State:_______ Zip: ____________ Phone: _________________. Release Information To: (please print). Name/Facility: ________________________________________ Attention: ______________. Address: ________________________________________ _____ Fax: ___________________.

ARIZONA ARTHRITIS & RHEUMATOLOGY ASSOCIATES, P.C. Phone: (480) 443-8400 Fax: (480) 443-8697 Authorization for Disclosure of Protected Health Information

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