www.sararadiology.com - Medical Records release to SARA

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION TO SOUTHERN ARIZONA RADIOLOGY ASSOCIATES
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.Format: (000) 000-0000.
Alternate Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Purpose of the Requested Use or Disclosure (check one)
If "Other" Please Explain
Releasing Facility/Practice
Contact Person
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
I hereby authorize the releasing facility/practice identified above to release and disclose to Southern Arizona Radiology Associates, a copy or an original 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

Other
I understand that I may revoke this authorization at any time by notifying the releasing facility/practice 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 the releasing facility/practice to send the information to be released by fax or electronically.
Notice: The releasing facility/practice 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
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION TO SOUTHERN ARIZONA RADIOLOGY ASSOCIATES