Records Request Form

Pineapple Health

Please correct the errors described below.

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:

Release Information:

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

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:

Form of Records:

*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.

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.

(Required for all patients 18 years and older for psychiatric records, 14 years and older for substance use records)
(Required for all patients under the age of 18 unless otherwise allowed by law. If not the parent, legal representation documentation must be supplied)

-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.