Transcription of Phone: (480) 443-8400 Fax: (480) 443-8697 Authorization ...
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Phone: (480) 443-8400 Fax: (480) 443-8697 Authorization ...
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: _____. City:_____State:_____Zip: _____ Phone: _____. Comment Box Information to be Released: (please print). Please provide a two year abstract of my records. Please provide my entire Medical Record for dates From:_____ to _____. Other: Please be specific. Example: X-rays of Spine done March 2008.
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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