* ROI - AUTHORIZATION TO ACCESS, USE, AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI)

AUTHORIZATION TO ACCESS, USE, AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI)
Reason For Disclosure *

Coordination of Care Personal Use
Type of Release (a) *

Release Recieve Both
Type of Release (b) *

Release
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.
Date of Records From:

Month Day Year
Date
Date of RecordsTo:

Month Day Year
Date
Release Authorization Information
Patient Information
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
Date
Patient Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Patient Phone Number *

Area Code Phone Number
Patient Email
example@example.com
Release Authorized By *

Patient Guardian
Guardian Name *

First Name Last Name
Relationship to Patient
Guardian Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Guardian Phone Number *

Area Code Phone Number
Fax Number

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

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

Phone: 602-685-6000
The following entity/individual is authorized to access, use and receive my PHI. To release the information requested below to: *
The following entity/individual is authorized to disclose my PHI. To receive the information requested below from: *
The following entity/individual is authorized to access, use and receive my PHI and/or disclose my PHI. To release the information requested below to and receive the information requested below from: *
Name *

First Name Last Name
Relationship to Patient
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Release Method (a) *

Mail To Requested Address Fax Email
Release Method (b) *

Mail To Requested Address Pick Up At Clinic Patient Portal Email
Pick Up at Clinic - Location *
Fax Number

Area Code Phone Number
Email
example@example.com
Documents
Nature of Information To Be Released *
If Other, Please Describe
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.
Today's Date: *
By signing my name electronically, I am agreeing that my electronic signature is the legal equivalent of my manual signature.
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:

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

Release Authorization Information

Documents