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Patient Authorization for disclosure of PHI

Patient Authorization for disclosure of PHI

By signing this authorization, I understand that:

  • Requests for copies of medical records are subject to Fee for Service in accordance with federal/state regulations.
  • I have the right to REVOKE this authorization at any time. I can revoke this authorization during my stay, please specify below.
  • After I discharge, revocation must be made in writing and presented to the Health Information Management Department at the following address: 2695 N. Craycroft Rd, Tucson, AZ   85712. Revocation will not apply to information that has already been disclosed in response to this authorization.
  • This authorization will expire one year from the date signed unless otherwise specified (Otherwise specified date).
  • Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this authorization.
  • Any disclosure of information carries with it the potential for unauthorized re-disclosure.
  • Copy of driver’s license or identification card must accompany all requests.


  • Patient Authorization for disclosure of PHI Form