HIPAA Compliant Authorization for the Release of Patient Information - Arizona Fire & Medical Authority - Rev. July 2020

Sep 17, 2026

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HIPAA compliant authorization form for requesting disclosure of protected patient information. The form authorizes and requests a designated custodian to release complete medical records and billing records, including items such as clinical notes, consultation documents, treatment records, test results, and billing statements. It addresses consent under federal alcohol or substance abuse record requirements, acknowledges that the information may include sensitive diagnoses and substance abuse, and defines expiration as two years from execution. It also covers revocation rights, re-disclosure, and signature by the patient or legally authorized representative.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

HIPAA Authorization Overview

Patient and Provider Details

Medical and Billing Records to Be Disclosed

Consent for Sensitive Information

Authorized Representatives and Compliance Statement

Revocation, Re-Disclosure, and Expiration

Signatures and Legal Representative Details

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION Arizona Fire & Medical Authority TO: Name of Healthcare Provider/Physician/Facility/Medicare Contractor 18818 N. Spanish Garden Drive Street Address Sun City West, AZ 85375 City, State and Zip Code RE: Patient Name: Date ofBirth: I authorize and request the disclosure of all protected information for the purpose of review and evaluation. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following: All medical records, meaning every page in my record, including but not limited to: office notes, face sheets, history and physical, consultation notes, inpatient, outpatient and emergency room treatment, all clinical charts, r ports, order sheets, progress notes, nurse's notes, social worker records, clinic records, treatment plans, admission records, discharge summaries, requests for and reports of consultations, documents, correspondence, test results, statements, questionnaires/histories, correspondence, photographs, videotapes, telephone messages, and records received by other medical providers. All billing records including all statements, insurance claim forms, itemized bills, and records of billing to third party payers and payment or denial of benefits for the period to . I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure of this type of information. This protected health information is disclosed for the following purposes: _________________________________________________________________________ This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2 .31, the restrictions of which have been specifically considered and expressly waived. You are authorized to release the above records to the following representatives of defendants in the above-entitled matter who have agreed to pay reasonable charges made by you to supply copies of such records: | Name of Representative
Representative Capacity ([e.g. attorney](e.g. attorney), records requestor, agent, etc.)
Street Address | | --- | | City, State and Zip Code I understand the following:
a. I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.
b. The information released in response to this authorization may be re-disclosed to other parties.
c. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.
Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until two years from date of execution at which time this authorization expires.
Signature of Patient or Legal Authorized Representative Date | Name and Relationship of Legally Authorized Representative to Patient

FAQs

What records does the authorization allow for release?

It authorizes disclosure of all protected medical information, including every page of medical records, and all billing records such as statements and insurance claim forms.

Can the released information include sensitive diagnoses and substance abuse records?

Yes. The form states the information may include sexually transmitted diseases, AIDS, HIV, and alcohol and drug abuse, and the patient authorizes release of that type of information.

How long is the authorization valid and can it be revoked?

The authorization remains in force and effect until two years from the execution date, and it can be revoked in writing at any time except to the extent information has already been released in reliance on it.

Sep 17, 2026

Upload by Ophelia