ROI - Medical

Authorization to Release Health Information

United Community Health Center - Maria Auxiladora, Inc.
United Community Health Center

1260 S Campbell Rd Bldg.2

Green Valley, AZ 85614

Phone: 520-407-5970

Fax: 520-407-5990
Para ver en español, haga clic en el menú desplegable de idiomas en la esquina superior derecha y seleccione Español
If the form is filled out incorrectly… please expect a call from medical records.

You can Call UCHC Medical Records Department for help and information @ 520-407-5900 Ext 7607.

NOTE: if you need to request records for multiple children, please create a form for each child.

(Please be advised that if you are requesting records for personal use this may incur a fee)

-Our third-party copy service (VRC) process all these requests.. for Updates on your request please call 520-202-5354
RELEASE information TO a Facility/Medical Office/Insurance Company/Attorney or individual/authorized personREQUEST records FROM a Facility/Medical Office
Facility/Medical Office/Insurance Company/AttorneyIndividual/Authorized Person
Facility Name*
Individual/Authorized Person Name*
Type 'self' if requesting records for yourself
Facility Address*

Street Address

Street Address Line 2

CityState

Zip Code
Individual/Authorized Person Address*

Street Address

Street Address Line 2

CityState

Zip Code
Facility Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Individual/Authorized Person Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Facility Fax*
Please enter a valid phone number.Format: (000) 000-0000.
Individual/Authorized Person Fax
Patient Information:
Patient First & Last Name*
Patient Date of Birth*

MonthDayYear
Enter month/day/year
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Transfer of CareInsurance Company UseMedical Office/Facility UseAttorneyPersonal UseOther
Information to be disclosed:
Dates of services being requested: FROM month/day/year TO month/day/year .
Date of service being requested: FROM*

MonthDayYear
Date
Date of service being requested: TO*

MonthDayYear
Date
Progress NotesConsultationsER Report/SummariesImmunizationsEKG/ECG ReportMedication ListLaboratory/Pathology Report(s)BH Psych NotesImaging/Radiology ReportsProblem ListMy Complete Medical RecordsOther
FaxMailEmail
Email for email delivery*
example@example.com
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), STI's, medications and/or HIV status, Psych Evaluations, Psychotherapy Notes, Drug/Substance Notes, Mental Health, Sexually Transmitted Infections, Diagnosis/Treatment of HIV or HIV related Illness.
If you want any records to be EXCLUDED from being released, please specify below:
By signing this authorization form, I understand that:

*I understand that I may revoke this authorization at any time, in writing, that the revocation will not apply to information that has already been released in response to this authorization, and that the authorization will automatically expire one year from the date of signature.

*I understand that there may be a retrieval and copy charge associated with this release.

*I understand that only information dated prior to the date of this authorization may be released.

*I do not authorize further release by the receiving requester to any third party, but I understand that once information is released pursuant to this authorization, the releasing facility or physician named above cannot prevent the re-disclosure of that information. You agree your electronic signature is the legal equivalent of your manual/handwritten signature. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.

*I understand that my participation is voluntary and that I am free to withdraw at any time, without giving a reason and without cost. I understand that I will be given a copy of this consent form if requested. I voluntarily agree to take part in the transfer of my records.
PatientAuthorized Person
Legal documentation is required for all authorized persons signing on patient's behalf if patient is over the age of 18.

Click here to upload legal documentation
Patient Printed Name*
Please use the link below to upload a copy of the patient's photo ID.

Click here to upload a copy of your Photo ID
Authorized Person Printed Name*
Patient Signature*

Clear
Authorized Person Signature*

Clear
Date*

MonthDayYear
Date
Relationship to Patient*
Reason Patient Unable to Sign*
Should be Empty:

Authorization to Release Health Information