Language
  • English (US)
  • Spanish (Latin America)
  • Image-34
  • Browse Files
    Cancelof
  • Consent for Disclosure of Confidential Information

  • Disclosure Information

  • Patient Information

  •  - -
  •  -
  • I hereby authorize:

    Terros Health

    3003 North Central Ave, Suite 400,

    Phoenix, AZ 85012

    Phone: 602-685-6000

  •  -
  • Documents

  • Nature of Information To Be Released

    • Treatment Plan
    • Progress Notes
    • Evaluations & Assessments
    • Labs/Immunizations/Imaging
    • Discharge
    • Medication LIst
    • MD/NP/PA Notes (medical notes)
  • I understand that information to be released may include reference to sensitive information related to mental and behavioral health, HIV/AIDS or other communicable diseases, and drug or alcohol use.

    I understand that I have the right to revoke this authorization at any time except to the extent that action has been already completed based on this authorization.

    This release is valid for 1 year from the date of execution unless revoked in writing.

    To revoke this authorization, I must submit a written revocation to the HIM department at Terros Health.

    I understand that my healthcare cannot be based on this authorization unless the purpose is solely to obtain and disclose information to a third party, such as an employer. I understand that this authorization is voluntary, and I will not be denied treatment if I refuse to sign this authorization, and that I may request a copy.

    I understand that the information disclosed by Terros Health with this authorization may be re-disclosed by the entity that receives this information and may no longer be protected by privacy regulations.

    I authorize Terros Health to disclose and/or receive medical information regarding my treatment to include any protected health information to/from the entity as indicated on this authorization form.

  • By signing my name electronically, I am agreeing that my electronic signature is the legal equivalent of my manual signature.

  • Clear
  •  - -
  • Should be Empty: