Arizona Medical Records Release Form 1
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Pediatric Surgery

Medical Records Release Form
Patient Name:_________________________________ Date of Birth:_______________
Patient/Guardian Authorization
You may use or disclose the following health care information:
All my health information including, but not limited to, AIDS/HIV and other Communicable
Disease Information, Behavioral Health Care/Psychiatric Care, Alcohol and/or Drug Abuse
Treatment, if any, unless specifically excepted: ____________________________________
Other _____________________________________________________________

You may disclose this health information to:
Name:______________________________
Address:_____________________________
Phone:_____________________________ Fax:___________________________
Do you want us to

fax or

mail your child’s medical records?

This authorization is valid for six (6) months from the date of signing and may be revoked at any
time by providing written notice of revocation. I understand I cannot revoke this authori