Doug Ducey Joey Ridenour
Governor Executive Director
Arizona State Board of Nursing
1740 West Adams Street, Suite 2000
Phoenix, AZ 85007-2607
Phone: (602) 771-7800
Homepage: 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 licensee under investigation. Please
complete the following consent form for these purposes:
NAME OF LICENSEE:
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
Name(s) of Pharmacy
I understand that my records may be protected under Federal Confidentiality Regulations and am
providing my written consent to the disclosure of these records.
(Signature of Licensee) (Date)
Return form to:
click to sign
signature
click to edit
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