Standard Authorization Of Use And Disclosure Protected Health Information.pages AZ 8140 AAA To Release Medical Records
User Manual: AZ 8140
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348 East Virginia Ave., Phoenix, AZ 85004 (480)897-6992 Fax (602)274-5225
705 South Dobson Rd., Chandler, AZ 85224 (480)897-6992 Fax (480)752-1757
4852 East Baseline Rd., #101 Mesa, AZ 85206 (480)897-6992 Fax (480)346-4685
8140 East Cactus Rd., #710 Scottsdale, AZ 85260 (480)897-6992 Fax (480)344-4465
21321 East Ocotillo Rd., #128 Queen Creek, AZ 85142 (480)897-6992 Fax (480)839-1874
Standard Authorization of Use and Disclosure of Protected Health Information
I hereby authorize use or disclosure of the named individual’s health information as described below:
Patient Name___________________________________________________________ Date of
birth__________________________
Information to Be Used or Disclosed
The information covered by this authorization includes:
______________________________________________________________________________________________________
______
______________________________________________________________________________________________________
______
Purposes of Disclosure
Information listed above will be disclosed for the following purposes:
______________________________________________________________________________________________________
______
______________________________________________________________________________________________________
______
Persons Authorized to Use or Disclose Information (Who is sending information)
Information listed above will be used or disclosed by:
______________________________________________________________________________________________________
______Name of person/organization
______________________________________________________________________________________________________
______Address/Phone/Fax
Persons to Whom Information May Be Disclosed (Who is receiving information)
Information described above may be disclosed to:
______________________________________________________________________________________________________
______Name of person/organization
______________________________________________________________________________________________________
______Address/Phone/Fax
Expiration Date of Authorization
This authorization is effective through ___/___/___ unless revoked or terminated earlier by the patient or the patient’s personal
representative.
Right to Terminate or Revoke Authorization
You may revoke or terminate this authorization by submitting a written revocation to Arizona Allergy Associates.
Potential for Re-disclosure
Information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. It may
not be possible to ensure your right to the protection of the privacy of this information once Arizona Allergy Associates discloses it to
another party.
Sensitive information
I understand that the information in my record may include information relating to sexually transmitted diseases, acquired
immunodeficiency syndrome (AIDS), or infection with the Human Immunodeficiency Virus (HIV). It may also include information
about behavior or mental health services or treatment for alcohol and drug abuse. Patient/Representative Initials _____
Rights of the Individual
You may inspect or copy information used or disclosed under this authorization.
You may refuse to sign this authorization.
Effect of Refusing Authorization
If you refuse to sign this authorization, Arizona Allergy Associates will not deny you any treatment except research-related
treatment.
Signature
___________________________________________________________
Name of Patient (Print or Type)
___________________________________________________________
Signature of Patient
___________________________________________________________
Date
___________________________________________________________
Signature of Patient Representative (Required if the patient is a minor or an adult who is unable to sign this form)
___________________________________________________________
11-2017/det
