Release of Information

*NOTE TO CLIENT: PLEASE DO NOT SIGN THIS DISCLOSURE AUTHORIZATION UNLESS ALL BLANKS HAVE BEEN COMPLETED AND YOU HAVE ASKED QUESTIONS ABOUT ANYTHING ON THIS CONSENT WHICH YOU DO NOT UNDERSTAND.

CONSENT FOR DISCLOSURE OF CONFIDENTIAL INFORMATION


Disclosure with client’s consent as per Title 42. Chapter 1, part 2, Federal register Volume 40, Number 127







To release the information requested below to: Grand Canyon Clinics, 2717 N Fourth St Ste 100, Flagstaff, AZ 86004 Phone # 480-442-4204 Fax # 888-877-0421 - Email admin@grandcanyonclinics.com

Extent of nature of information to be disclosed: (check those that apply)

1. Complete Medical Records 2. Medical diagnosis/or evaluations 3. History 4. Discharge Summary
5. Treatment plans/progress notes 6. Lab Tests, X-Rays

This consent to release medical information expires 90 days from date signed unless revoked prior to that time by the client. I have read the above and fully understand the consent to release medical records. I have been given the opportunity to ask questions, if any, which have been answered to my satisfaction. I understand this consent is subject to revocation by me at any time except to the extent that action has already been taken on it.

[Digital Signature of Client:]