Authorization for Release Form - Physicians Health Center

Authorization to Release or Request Protected Health Information
Patient Information
Name*
Home Address*

Street Address Line 2
DOB*

MonthDayYear
Phone number*
Name Of Provider Or Healthcare Facility Releasing Information
Provider
Address
Phone Number
Fax
From

MonthDayYear
Start Date
To

MonthDayYear
End Date
Name Of Provider Or Healthcare Facility Requesting Information [Send To]:
Provider: Physicians Health Center/ Dr Amardeep Majhail

Address: 14674 W Mountain View Blvd Suite 100

City: Surprise State: AZ Zip Code: 85374

Phone Number: 623-600-2406

Fax: 623-900-7878
Signature Required*

Clear
I understand that by signing and submitting this form, I am authorizing the name of the clinic below to receive my complete heath records electronically, in accordance with 21st Century Cures Act:
PHYSICIANS HEALTH CENTER

Name of Clinic
Note: Providers could incur significant penalties if OIG determines an organization or provider committed INFORMATION BLOCKING
My complete health records including*

Mental HealthHIV or AIDSCommunicable diseasesTreatment of alcohol/drug abuseDiagnosis, lab tests, prognosis, treatment, and billing for all conditionMedical Treatment or consultationBilling or claims payment.
I understand the following:
- This authorization is valid for the information already in existence and any information that may be generated while this authorization is effective.
- The revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
- I have the right to see any information that is disclosed pursuant to this authorization for release, and I may request to see this information during normal business hours.
- Authorizing the disclosure of this information is voluntary and I can refuse to sign this authorization.
- I need not sign this form to assure treatment, payment or eligibility for services.
- I can revoke my authorization at any time and that the revocation will not apply to information that has already been released in response to this authorization.
- If the person or organization authorized to receive this information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations. However, there may be other federal or state laws that require the information to remain confidential.
I acknowledge that I have read this form, or it has been read to me and I understand its content.
Print your name here*
From

MonthDayYear
Start Date
To

MonthDayYear
End Date
Sign Your name here*

Clear
Fill in today’s date here*

MonthDayYear
Should be Empty:

Authorization to Release or Request Protected Health Information

Patient Information

Name Of Provider Or Healthcare Facility Releasing Information

Name Of Provider Or Healthcare Facility Requesting Information [Send To]:

PHYSICIANS HEALTH CENTER

I understand the following: