Recipient: I authorize my health care information to be released to the following recipient(s):
Name: Phusion Wellness
Address: 10207 E Hampton Ave
Mesa, AZ 85209
Phone: (480) 559- 3149
Fax: (855) 822-6349
Email: info@phusionwellness.com
Address: 7611 Jordan Landing Blvd. #103
West Jordan, UT 84084
Phone: (801) 486-1616
Fax: (855) 822-6349
Email: info@phusionwellness.com
Purpose: I authorize the release of my health information to Phusion Wellness for the purpose of opioid therapy.
Information to be disclosed: All of my health information that the provider has in his or her possession, including:
- Information relating to any medical history
- Information relating to any mental health or physical condition
- Information relating to any treatment received by me
- HIV test results
- Information relating to outpatient psychotherapy
- Information relating to drug and alcohol treatments
Term: I understand that this Authorization will remain in effect for one year from the date signed.
Redisclosure: I understand that my health care provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.
Right to revoke: I understand that I can revoke this authorization by providing a written notice of revocation to Phusion Wellness.
Questions: I may contact Phusion Wellness at the contact information listed below.
10207 E Hampton Ave, Mesa, AZ 85209 | 7611 Jordan Landing Blvd #103 West Jordan, UT 84084 | www.phusionwellness.com | Phone AZ: (480) 559-3149 | Phone UT: (801) 486-1616 | Fax: (855) 822-6349