AUTHORIZATION OF USE & DISCLOSURE
OF PROTECTED HEALTH INFORMATION
DESERT RADIOLOGY AUTHORIZATION OF USE & DISCLOSURE
OF PROTECTED HEALTH INFORMATION 2021
702.759.8600 | WWW.DESERTRAD.COM
OFFICE USE ONLY – Patient PID: ______________________
Patient Name:__________________________________________________________________ DOB: _________________________
I authorize Desert Radiology the use and disclosure of Protected Health Information. My personal identifying information is as listed
above. The information to be used and disclosed covered by this authorization includes medical records, films, billing information, etc.
Family Member/Persons/Group to whom information may be disclosed: (Name / Address / Phone or Fax #)
________________________________________________________________________________________________________________________
Name Address Phone / Fax
The Protected Health Information will be Used and Disclosed as follows: (check box that applies)
Request of the patient
Other:
This authorization is effective through (mm/dd/yyyy) unless revoked or terminated by the patient or
the patient’s personal representative. You may revoke or terminate this authorization by submitting a written revocation to Desert
Radiology. You should contact the Medical Records Department (702.759.8750) to terminate this authorization. Revocation will
exclude disclosures made prior to effective date of revocation. Please note that the person or organization to which we disclose PHI
may further disclose information that is disclosed under this authorization. The privacy of this information may not be protected
under the federal privacy regulations.
Request for Protected Health Information from another Provider (Privacy Rule 45 CFR 164.506)
In an effort to obtain continuation of care without any delay, I authorize the following health care providers to release any and all
necessary health care information to Desert Radiology:
Provider Name: _____________________________________________________________________________________________
Provider Address: _____________________________________________________________________________________________
Provider Phone: _________________________________________ Provider Fax: __________________________________________
Please send records to the medical records department at:
Desert Radiology
Attn: Medical Records Department
3930 S. Eastern Avenue
Las Vegas, NV 89119
Desert Radiology will not condition treatment on whether the patient signs this authorization unless the treatment is research related
or the treatment is for the purpose of creating PHI for disclosure to a third party such as life insurance or for disability examinations.
____________________________________________________________________________________________________________
Signature of Patient/Patient’s Representative Date
_________________________________________________________
Relationship to Patient
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