Doug Ducey Joey Ridenour
Governor Executive Director
Arizona State Board of Nursing
1740 W. Adams Street, Suite 2000
Phoenix AZ 85007-2607
Phone (602) 771-7800
Secure E-mail: https://www.virtru.com/secure-email/
Home Page: http://www.azbn.gov
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
It is often essential that information be exchanged between the investigator and persons involved
in evaluating mental and physical health treatment for DSSOLFDQWOLFHQVHFHUWLILFDWHKROGHU
under investigation. Please complete the following consent form for these purposes:
NAME OF 3$7,(17
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
This Consent Form authorizes the medical provider to disclose information/records to Arizona
State Board of Nursing, for the purpose of completing an investigation pursuant to A.R.S. § 32-
1664.
Name of Medical Provider/Facility
Street
City, State Zip Code
My Prescriptions are filled at
I understand that my records may be protected under Federal Confidentiality Regulations and am
providing my written consent to the disclosure of these records.
Return form to:
click to sign
signature
click to edit
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