Authorization to Use or Disclose
Protected Health Information (PHI)
PATIENT IDENTIFICATION – PLEASE PRINT LEGIBLY
Name __________________________________________
Addr
ess ________________________________________
_______________________________________________
City State Zip
Phone _________ - _________ - _______________
Date of Birth ____ / _____ / _____
Approximate Date(s) of Service___ /___ /___
Dr./Office N
ame ________________________
INFORMATION REQUESTED / DELIVERY REQUIREMENTS – MUST CHECK A BOX
Send results via: Secure fax: __________________ Mail to address above
Secure email (enter in boxes below): Mail to address below
Complete ONLY if requesting results via email:
Send results encrypted Do not send results encrypted
*Unencrypted information sent via email can be intercepted by unauthorized parties*
Sonora Quest Laboratories relies on information provided by the physician at the time the laboratory test is ordered. The information
provided by the physician may not be sufficient to accurately match the information you provide on this form. In such cases, Sonora
Quest Laboratories will protect our patient’s privacy by not releasing results that do not conform to our strict criteria for determining
matches. Failure to provide all information we request may prevent us from identifying some of your records.
I und
erstand that information in my health record may include information relating to Sexually Transmitted Diseases, Acquired
Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV), and other communicable diseases, Behavioral Health
Care/Psychiatric Care, treatment of alcohol and/or drug abuse and genetic testing. My signature authorizes release of such
information.
I m
ay refuse to sign this authorization form. I understand that Sonora Quest Laboratories will not condition or deny treatment on my
signing this authorization.
I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has
already been taken.
Unle
ss I revoke this authorization earlier, it will expire six (6) months from the date signed
or on ___/___/___.
I un
derstand that, if this information is disclosed to a third party, the information may no longer be protected by state, federal
regulations and may be re-disclosed by the person or organization that receives the information.
I r
elease Sonora Quest Laboratories, its employees and agents, medical staff members, and business associates from any legal
responsibility or liability for the disclosure of the above information to the extent indicated and authorized herein.
______________________________________ ______________________________________
Signature of Patient Date
In requesting the medical records as the designated agent, in signing below, I attest to the continuing inability of the above patient
to make or communicate health care decisions.
____________________________________ ___________________________________
Signature of Legal Representative Relationship to Patient or Description of
Authority to Act for Patient
Completed forms may be mailed, scanned and emailed, faxed, or dropped off at any of our Patient Service Centers
Sonora Quest Laboratories
ATTN: HIMS Department
424 S. 56th St., Ste. 100
Phoenix,
AZ 85034
Fax to: 602.685.5553
Email to:
DTP-Arizona@SonoraQuest.com
INFORMATION TO BE DISCLOSED TO:
____________________________________________________________ _________ - _________ - _______________
Company, Person, Facility Phone Number (Including Area Code)
__________________________________________________________ ____________________________ _______ _______________
Street Address City State Zip
Internal use only:
Date received:________________
Tr
acking #:___________________
____________________________
25238 (Rev 9/2020)
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