Authorization for Medical Information Exchange July 2023

Authorization for

Medical Information Exchange

Para ver este formulario en español, haga clic en el menú desplegable en la esquina superior derecha.

Patient Name*

First NameMiddle NameLast Name

Date of Birth*

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState

Zip Code

As a patient, parent or guardian, I hereby authorize the release of medical records from and to United Community Health Center for the purpose of continuity of care. I understand that medical information gathered from or given to other facilities, specialists and hospitals is vital to ensuring that the highest quality healthcare services are delivered to me and my family.

United Community Health Center:
1260 S Campbell Road
Building 2
Green Valley, AZ 85614
Phone: 520-407-5600
Fax: 520-407-5990

United Community Health Center provides integrated medical, dental, and behavioral health services. Records released may contain information related to all integrated services provided at our facilities unless noted below. I understand that my medical record may also include information on diagnosis/treatment related to psychiatric or psychological conditions, drug and/or alcohol abuse, acquired immune deficiency syndrome (AIDS), STD's, medications and/or HIV status.

I understand and agree that the information, if any, pertaining to any such diagnosis/treatment described above may be released, except those exclusions/limitations noted below.

Exclusions/Limitations (if any)

Expiration: I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization. Unless otherwise revoked, this authorization will expire 2 (two) years after signed date.

Signature*

Who is signing this form?*

PatientParent/GuardianOther

Relationship to Patient*

If Patient is not signing

Today's date*

*required field

Please verify that you are human*