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.
*****THIS AUTHORIZATION FORM IS ONLY VALID WHEN FULLY COMPLETED*****