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| Date: |
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| Full Name: |
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| Address: |
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| City:State:Zip: |
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| Date of Birth:Phone: () |
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| Signature: |
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| I understand that if all spaces are not filled out completely my records will not be sent/received in a timely manner. |
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| Print Name if not Patient: |
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| Relationship to Patient: |
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| Please choose only one!!! |
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| [ ] I hereby authorize MESA FAMILY PHYSICIANS to RECEIVE medical records from the provider listed below. Please fax to the Mesa Office (480) 644-1372 [ ] or to the Gilbert office (480) 632-5923 [ ] (Please check only one). |
| [ ] I hereby authorize MESA FAMILY PHYSICIANS to SEND medical records to the provider listed below. |
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| PROVIDER'S NAME: |
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| Full Address: |
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| City: State: Zip: |
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| Phone: () Fax: () |
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| Please send records from the past two years unless otherwise specified. |
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| "MEDICAL RECORDS" AND "X-RAY FILMS" SHALL INCLUDE ALL CONFIDENTIAL AND HIV-RELATED INFORMATION (AS DEFINED IN A.R.S. SECTION 36-661), CONFIDENTIAL COMMUNICABLE DISEASE-RELATED INFORMATION (AS DEFINED INS A.R.S. SECTION 36-661), CONFIDENTIAL ALCOHOL OR DRUG ABUSE-RELATED INFORMATION (AS DEFINED 42 CFR SECTION 2.1 ET SEQ.), AND CONFIDENTIAL MENTAL HEALTH DIAGNOSIS/TREATMENT INFORAMATION. |
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| PRINT FORM | CLOSE |