www.sararadiology.com - Medical Records release from SARA

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
Patient’s Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Telephone Number*
Please enter a valid phone number.
Alternate Telephone Number
Please enter a valid phone number.
Email*
example@example.com
Purpose of the Requested Use or Disclosure (check one)*

Continuing Medical CareAt My RequestFiling Insurance AppealOther
If "Other" Please Explain*
I hereby authorize Southern Arizona Radiology Associates (SARA) to release to the recipient identified below a copy of the following protected health information, including any confidential HIV/AIDS-related information, confidential communicable disease-related information, and/or information relating to any mental health and/or alcohol/drug use

OrdersImages (CD)Radiology ReportsCorrespondenceEntire RecordImages (email link)Other
Images (email link)
example@example.com
Please allow 24-48 hours to process your request
Recipient
Contact Person
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number
Please enter a valid phone number.
Fax Number
I understand that I may revoke this authorization at any time by notifying SARA in writing, except to the extent that action based on this authorization has already been taken. Unless revoked, this authorization will expire on If no date is provided it shall automatically expire six (6) months from the date on which it is signed. I agree to allow SARA to send the information to be released by fax or electronically
Notice: SARA may not condition treatment, payment, enrollment or eligibility for benefits on whether you sign this authorization. Information disclosed pursuant to this authorization may be subject to redisclosure by the Recipient and may no longer be protected by federal privacy laws.
Patient/Representative signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
If you are a Personal Representative, you must provide a description of your authority to act for the patient.
Should be Empty:

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION