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:
The protected health information that may be used or disclosed, initial all that apply:
Dates of records:
OR If no dates are specified, one (1) year will be released.
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
This authorization shall be in force and effect until:
*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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