Authorization for Use of Disclosure of Protected Health Information

I (state Name below) hereby authorize Canyon Pediatrics: 2451 E Baseline #200 Gilbert, Az 85234 and 815 E University Rd Mesa, Az 85203 Medical Records Phone Number 480-507-2199 Fax Number 480-649-3416 to (initial all that apply) Disclose and/or Request my protected health information from the following:

I am requesting medical records from another provider to be sent to Canyon Pediatrics

I am releasing my Canyon Pediatrics medical records to another provider

Patient's Name:

Date Of Birth

Name of person/organization:

Address of person/organization:

The protected health information that may be used or disclosed, initial all that apply:

Entire Record

Entire Record:

Only information related to

Only information related to: (Specify)

Only the period event from

Only the period event from:

to:

Other:

Other: (Specify)

School Records

School Records:

Immunizations

Immunizations:

Behavioral Health Treatment notes

Behavioral Health Treatment notes:

Psychiatric Evaluations and progress notes

Psychiatric Evaluations and progress notes:

Dates of records:

From:

To:

OR If no dates are specified, one (1) year will be released.

Purpose of Disclosure:

I understand that my records are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written consent. I certify that this consent has been given freely and voluntarily. I understand that services are not contingent upon my authorization for use and/or disclosure of information. I have the right to revoke this authorization at any time, except to the extent that action has already been taken on this authorization and will automatically expire on the date and/or conditions specified below.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Signature of Parent /Guardian:

Date of signature (this authorization is valid for 1 year from this date or as otherwise specified above):

I REVOKE this authorization on:

Signature of Parent/Guardian:

I DECLINE release of information to:

on:

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Signature of Parent/Guardian:

Reason for declining release:

This authorization shall be in force and effect until:

Expiration Date:

One year No Expiration

Expiration Date:

Other Condition:

event that relates to the patient or the purpose of the use of disclosure:

at which time this authorization to use or disclose this protected health information expires.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Other required signature (if applicable):

Witness signature:

[Provide a copy of this form to consumer.]

Relationship to Consumer:

*If consumer is a minor, both his/her signature is required with signature of parent/legal guardian.

Notice: Alcohol and drug abuse patient records are protected by Federal confidentiality regulations (42CFR part 2). The Federal regulations prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains of as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal regulations restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. Communicable disease related information, pursuant to this release, cannot be redisclosed without specific written authorization (A.R.S. 36-664. H)

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