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  • AUTHORIZATION TO ACCESS, USE, AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI)


  • Please enter the date range for the records to be released.  If no dates are specified, records will be released one year prior to the last date of service.

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  • Release Authorization Information

  • Patient Information

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  • I hereby authorize:

    Terros Health
    3003 North Central Ave, Suite 400,
    Phoenix, AZ 85012

    Phone: 602-685-6000

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  • Documents

  • 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.

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