HD-21 (Revised. 3/16/2004)
PIMA COUNTY HEALTH DEPARTMENT
AUTHORIZATION TO RELEASE MEDICAL INFORMATION
Description of Purpose for Release: Patient Request _____ Or Other Reason (Describe Below):
INFORMATION REQUESTED FROM:
NAME:
ADDRESS:
CITY: STATE: ZIP CODE: TELEPHONE:
SEND MEDICAL INFORMATION TO:
NAME:
ADDRESS:
CITY: STATE: ZIP CODE: TELEPHONE:
PATIENT INFORMATION:
FIRST NAME: MIDDLE: LAST NAME: BIRTH DATE:
ADDRESS:
CITY: STATE: ZIP CODE: TELEPHONE:
MOTHER’S MAIDEN NAME: MR#:
INFORMATION REQUESTED:
PATIENT TO INITIAL AREAS TO BE RELEASED:
__________HISTORY/PHYSICAL
__________LAB RESULTS
__________X-RAYS
__________TREATMENT PLAN
__________FAMILY PLANNING
__________STD
__________PROGRESS NOTES __________OTHER:________________________
__________DRUG/ALCOHOL
__________HIV/AIDS
__________PSYCHIATRIC
__________COLPOSCOPY
__________WIC
I UNDERSTAND THAT THIS MEDICAL INFORMATION MAY INCLUDE INFORMATION RELATING TO THE FOLLOWING AND I
AGREE TO ITS RELEASE UNLESS I INDICATE NO.
YES_____ NO_____ AIDS (ACQUIRED IMMUNODEFICIENCY SYNDROME) OR HIV (HUMAN IMMUNODEFICIENCY VIRUS)
YES_____ NO_____ BEHAVIORAL HEALTH CARE
YES_____ NO_____ TREATMENT FOR ALCOHOL AND/OR DRUG ABUSE
YES_____ NO_____ GENETIC COUNSELING, TESTING
I understand that a covered agency may not condition treatment, payment, enrollment or eligibility upon obtaining this authorization, except
where federal law allows such condition.
I understand that if the agency authorized to receive the health information is not a health plan or health care provider, the released information
may no longer be protected by federal privacy regulations and may be subject to re-disclosure.
This authorization may be revoked in writing at any time, except to the extent that action has been taken based upon the authorization.
Instructions for revocation are contained in the Pima County Health Department Notice of Privacy Practices. This authorization will expire one
year from today’s date, or upon the following date or event:_________________________________________________________________________
SIGNATURES:
PATIENT: DATE OF SIGNATURE:
LEGALLY AUTHORIZED REPRESENTATIVE:
RELATIONSHIP TO PATIENT:
