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 firstname.lastname@example.org
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.