Disclosure (English) - Consent for Disclosure of Confidential Information

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Consent for Disclosure of Confidential Information
Type of Release *

Disclosure
Reason For Disclosure *

Coordination of Care
Disclosure Information
Patient Information
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
Date
Patient Address

Street Address

Apt/Bldg/Unit#

City State / Province

Postal / Zip Code
Disclosure Authorized By

Patient Guardian
Authorizer's Name *

First Name Last Name
Relationship to Client
Phone Number *

Area Code Phone Number
Email
example@example.com
I hereby authorize:

Terros Health

3003 North Central Ave, Suite 400,

Phoenix, AZ 85012

Phone: 602-685-6000
To Release Information To *

First Name Last Name
Relationship to Patient
Address *

Street Address

Apt/Bldg/Unit#

City State / Province

Postal / Zip Code
Disclosure Method

Phone Email In Person
Phone Number

Area Code Phone Number
Email
example@example.com
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.
(Today's Date) *
Patient/Guardian Signature: *

If client is under the age of 18, I certify that I am authorized to seek medical treatment on behalf of this child. Clear
Type Patient/Guardian full name here *
Date of Patient/Guardian Signature *

Month Day Year
Should be Empty:

Consent for Disclosure of Confidential Information

Disclosure Information

Documents