Request Medical Records

Authorization to Release Healthcare Information
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Telephone
Best Phone Number to Reach YouFormat: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
I request and authorize Sonoran Spine Center to release healthcare information of the patient named above to:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
Format: (000) 000-0000.
FAX
This request and authorization applies to healthcare information relative to my diagnosis, treatment, prognosis, and/or recommendations, as well as other data pertinent to my condition during the past two years.

Other
I authorize the release of photocopies of the medical records and/or X-ray films in yourpossession or control FOR THE PURPOSE HEAROF: “MEDICAL RECORDS” AND “X-RAYSFILMS” SHALL INCLUDE ALL CONFIDENTIAL HIV RELATED INFORMATION,CONFIDENTIAL COMMUNICABLE DISEASE RELEATED INFORMATION 9AS DEFINED INA.R.S.SECTION 36-661). CONFIDENTIAL ALCOHOL OR DRUG ABUSE RELATEDINFORMATION (AS DEFINED IN 42 CFR SECTION 2.1 ET SEQ), AND CONFIDENTIALMENTAL HEALTH DIAGNOSIS/TREATMENT INFORMATION.
Signature of Patient/Parent or Guardian
Relationship to Patient
Date

MonthDayYear
Date
PLEASE ALLOW 7-10 BUSINESS DAYS FOR COMPLETION THIS AUTHORIZATION EXPIRES ONE YEAR AFTER IT IS SIGNED
Should be Empty:

Authorization to Release Healthcare Information