This form is a consent to the release of medical history. The patient authorizes the release of his/her medical history to the specified party within the consent release form. The form also provides that all prior authorizations are cancelled.
Consent Form For Release Of Information In Maricopa
State:
Multi-State
County:
Maricopa
Control #:
US-00460
Format:
Word;
Rich Text
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This form is required for each college institution you attend. Please send a cashier's check, business check or money order payable to MARICOPA COUNTY CORRECTIONAL HEALTH SERVICES.No personal checks will be accepted. Financial records or bank account information. If you prefer to mail your public records request, complete this form, print, and mail to the address listed. If you need copies of your records, complete and sign a Authorization to Use or Disclose Protected Health Information Form. Human Remains Release Form (HRRF). Completion Guidance. O If you would like to register your documents with the Arizona Health Care Directives. Registry, you MUST fill out this form and submit it with your documents.