Records Request Form

Authorization to Disclose Health Information

I, the undersigned, authorize:
Pineapple Health/Rejenesis
12010 S. Warner-Elliot Loop
Phoenix, AZ 85044
Phone: 480-961-2366 Fax: 480-961-2367

Patient Information:

Patient Full Name

Other Names During Treatment?

Patient Address:

City:

State:

Zip:

Release Information:

Please select

TO FROM

-This box must be completed in order for the request to be processed-

Name/Facility:

Attention:

Address:

City:

State:

Zip:

Phone:

Fax:

Authorization to Disclose Health Information: Purpose of Request Purpose of Request:

Personal

Treatment

Legal

Insurance

Disability

Transfer/Reason

Other

If Transfer/Reason, please explain:

If Other, please specify:

Information to be Released:

Section 1:

For personal requests, there will be a $15 flat fee and $0.25 per page fee for all requests on paper(plus the cost of postage and envelope) or there will be a $10 flat fee and a $0.25 per page fee for all requests on CD (plus the cost of postage and envelope). Please be specific in the information you would like in Section 2:

For doctor to doctor requests, there will be no fee. By default, the past two years of pertinent information will be sent. Please provide any specific additional information in Section 2:

Section 2:

Please provide information in my medical record for dates:

From:

To:

History and Physical Examination

Office Visit Note

Laboratory Tests

X-Rays/Imaging Reports

Other

If Other, please specify:

Form of Records:

Please Choose:

Records on Paper Records on CD

If Records on CD, please provide 4 Digit Encryption Key:

*If no encryption key is provided, encryption key will be included with CD upon delivery.

Authorization to Release Protected:

*Required - Please complete the choices below indicating how protected information should be handled even if the categories do not necessarily apply to the patient's medical records.

DO DO NOT want information on *Mental Health to be released

Initial

DO DO NOT want information on *HIV tests & Related information to be released

Initial

DO DO NOT want information about *Alcohol and/or Substance Abuse released

Initial

DO DO NOT want information about *Communicable Diseases released

Initial

STOP: Please confirm that you have selected and initialed all the protected information categories above regardless if they are applicable or not. If the form is incomplete, or if protected information is not released, we may be unable to fulfill this request.

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

Patient's Signature:

(Required for all patients 18 years and older for psychiatric records, 14 years and older for substance use records)

Date:

Signature of Parent or Legal Guardian:

(Required for all patients under the age of 18 unless otherwise allowed by law. If not the parent, legal representation documentation must be supplied)

Date:

-This authorization will expire 90 days from the date appearing above. I understand that I may revoke this authorization at any time by notifying the Health Information Management Department in writing, but if I do, it will not have any effect on the actions the hospital took before it received the revocation.

-I understand that under the applicable law the information used or described pursuant to this authorization may be subject to redisclosure by the recipient and no longer subject to the protections of the privacy standard.

-I understand that my treatment or continued treatment by PineappleHealth/Rejenesis and its affiliates is no way conditioned on whether or not I sign the authorization and that I may refuse to sign it.

-I understand that I may inspect or copy the information that is used or disclosed

Your information will be encrypted.