Patient Identifying Information:
Patient Name: ___________________________________________ Date of Birth: _______________________________
Address: ___________________________________________City______________ State___________ Zip Code_______
Phone Number: ______________________________ Date (s) of Service(s): _____________________________________
Release of medical records to Arizona State Urology:
I authorize _________________________ to release my medical records as I have indicated in Section 2:
Disclose to: Arizona State Urology
Address: 6525 W. Sack Drive Suite 201 Glendale, AZ 85308
Phone: 602 337-8500 Fax: 602 337-8151
2. Specific Description of Information to Be Disclosed (check all that apply):
______ Discharge Summary, History and Physical Exam, Operative Reports, Consultation reports
______ X-ray Reports, Pathology, Lab Testing, Progress Notes
______ Pertinent Records Only Other (Specify)_____________________________________________
Specific description of the purpose of disclosure:
______ The disclosure is at the patient’s request Other(Specify)________________________________
I authorize the provider to use or disclose information related to:
_______ AIDS/HIV _______ Genetic Testing Information
_______Psychiatric Care Reports _______ Alcohol and/or Drug Abuse Treatment
I understand that Arizona State Urology, PC will not condition on my signing this authorization. Arizona State Urology, PC will not
deny me treatment if I do not wish to sign this form. I may refuse to sign this authorization form. I also understand that I may revoke
this authorization at any time with some exceptions. For more details on when I can or cannot revoke this authorization, I can read
Arizona State Urology, PC Notice of Privacy Practices.
To revoke my authorization, I must submit written request to Arizona State Urology, PC. Unless I revoke the authorization earlier, it
will expire upon its completion or 180 days from the date of signature, whichever comes first. I understand that, if this information is
disclosed to a third party, the information may no longer be protected by the federal privacy regulation and may be re-disclosed by
the person or organization that receives the information. I understand the matters discussed on this form. I release the provider, its
employees, officers and directors, medical staff members, and business associated to the extent indicated and authorized herein.
Signature of Patient: ___________________________________________ Date: _______________________________
Signature of Legal Representative: _______________________ Relationship to Patient: _________________________
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