Authorization to Disclose Personal Information

Patient Authorization to Disclose Personal Information

Patient Full Name(*)

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Address(*)

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Email address(*)

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Date of Birth(*)

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Telephone No.(*)

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Phoenix Family Medical Clinic/ Phoenix Clinica Familiar is authorized to(*)

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Physician(*)

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Phone #(*)

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Fax #(*)

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Address(*)

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I authorize release of the following medical records(*)

I GIVE PERMISSION TO RELEASE ALL MY MEDICAL RECORDS including information and records or copies relating to the history, diagnosis, treatment or services rendered to me in connection with any condition or disease. This includes permission to release POTENTIALLY SENSITIVE INFORMATION which may include information concerning my treatment of mental illness, sexual assaults, abortion, illegitimacy of birth, communications to social workers and/or psychotherapies, psychologists, if any.I GIVE PERMISSION TO RELEASE ONLY RECORDS specifically described belowPlease select an option

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I released Phoenix Family Medical Clinic/ Phoenix Clinica Familiar and the Recipent/Disclosure listed above, and any of their providers and staff from all responsibility or liability that may arise from this authorization. I may withdraw this authorization at any time by giving written notification to Phoenix Family Medical Clinic/ Phoenix Clinica Familiar, provided that I do so in writing and to the extent that you have already disclosed the information in reliance on this authorization.

This Authorization expires on

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(Optional) If no expiration date is given, then this authorization shall remain in effect for a period reasonably needed to complete the request.

Same Day Appointments & Walk-Ins Welcome

Most Plans & AHCCCS Accepted

Open Saturdays in Three Convenient Locations

Women's Health, Men's Health & Well Child Exams

On Site Blood Draws & Lab Work

Patient Authorization to Disclose Personal Information