Release of Information

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Patient Name

First

Last

Date of Birth

Release to

I am requesting medical records from another provider to be sent to Canyon Pediatrics
I am releasing my Canyon Pediatrics medical records to another provider

Name of Person or Organization

Address of person or Organization

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email of Organization

Person Making Request

Medical Release or

Email or Phone of Requester

Medical Records Release Terms & Conditions

I (name above) hereby authorize Canyon Pediatrics: 2451 E Baseline #200 Gilbert, Az 85234 and 815 E University Rd Mesa, Az 85203 Medical Records Phone Number 480-507-2199 Fax Number 480-649-3416 to (initial all that apply) Disclose and/or Request my protected health information from the following:and conditions for your release form. This field is marked as required and has to be ticked to be submitted.

1. YOUR AGREEMENT

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

Patient or Guardan Signature

Clear Signature

Date

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