Authorization to Release Health Information

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107 N Greenfield Rd Suite 1 Mesa, AZ 85205

Phone: (480) 741-8041

Fax: (480) 741-8045

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Designated Individual(s) to Receive Information

Without this consent we cannot:

Speak to anyone other than the patient, including significant others, parents, or other family members. This includes all protected health information.

I authorize Sanitas Medical Group to disclose my personal health information to the following individual(s):

Full Name

Relationship to Patient:

Date of Birth:

Phone Number:

Full Name

Relationship to Patient:

Date of Birth:

Phone Number:

Scope of Information to be Disclosed

Check all that apply:

Appointment Information Billing and Insurance Information Test Results Medication Information All Medical Information Other (please specify):

Duration of Authorization

This authorization is valid:

Until revoked in writing Until the following date For the duration of treatment

Patient Rights

I understand that I may revoke this authorization at any time by notifying Sanitas Medical Group in writing.

I understand that revocation will not affect any actions already taken in reliance on this authorization.

I understand that I am not required to sign this form to receive treatment.

I understand that information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations.

Patient Signature:

Dedicated to keeping our community healthy with compassionate doctors and patient-centered care you can trust.

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GREENFIELD OFFICE

(480)741-8041

EMAIL US AT:

primarycare@desert-mtn.com

LOCATION:

107 N Greenfield Rd Suite 1 Mesa, AZ 85205

Monday - Friday: 9:00am – 4:00pm
Wednesdays: Phones Only
Saturday & Sunday: Closed

LOCATION:

Leisure World, 908 S power rd Mesa, AZ 85206

Monday - Friday: 8:00am – 1:00pm
Saturday & Sunday: Closed

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