Select Method of Delivery:

☐ MAIL	☐ PICKUP (by scheduled appointment only)	☐ FAX ☐ EMAIL

Patient Name	Date of Birth
Account #	Telephone #
Admission Date	Discharge Date
Current Address	Email

PLEASE RELEASE THE FOLLOWING INFORMATION:

☐Admission Face Sheet	☐Physician Orders	☐Respiratory Treatment Notes	☐Radiology Film/CD

☐Discharge Summary	☐Progress Notes	☐Medication Record	☐Cardiology Film/CD

☐History and Physical	☐Radiology Reports	☐Rehab (PT/OT/ST) Record	☐Billing Records/Financial Records

☐Consultation Reports	☐Pathology Reports	☐HIV/AIDS Testing	☐Operative Report

☐Lab Results	☐Treatment/Diagnosis	☐Emergency Department Records	☐Cardiology Reports

☐Mental Health Information	☐Other, please specify

MY HIGHLY CONFIDENTIAL INFORMATION

By checking any of the boxes next to a category of highly confidential information listed below, I specifically authorize the use and/or disclosure of the category of highly confidential information indicated next to the box, if any such information will be used or disclosed pursuant to this authorization:

☐ Information about mental health or mental retardation services

☐ Psychotherapy notes created by a mental health professional

☐ Information about HIV/AIDS-related testing (including the fact that an HIV test was ordered, performed, or reported, regardless of whether the results of such test were positive or negative)

☐ Information about sexually transmitted diseases

☐ Information about alcohol or drug abuse treatment program services

☐ Information about sexual assault

☐Information about child abuse and neglect

I HEREBY AUTHORIZE:

☐Carondelet St. Joseph’s Hospital, Tucson, AZ ☐Carondelet St. Mary’s Hospital, Tucson, AZ ☐Carondelet Holy Cross Hospital, Nogales, AZ

☐Carondelet San Raphael Emergency Center, Tucson, AZ	☐Carondelet Marana Hospital, Marana, AZ

☐RECIPIENT: Name and address of person or class of persons to whom Carondelet Health Network may disclose my health information:

Name
Street
City	State	Zip
Email Address

☐TERM: This authorization will remain in effect (if left blank, this authorization will remain in effect for 365 days or one year):

☐From date of this authorization until the day of	, 20

☐Until Carondelet Health Network fulfils this request

☐Until the following event occurs:

☐Other:

☐PURPOSE: I authorize Carondelet Health Network to use or disclose my health information (including highly confidential information (selected above, if any) during the term of this authorization for the following specific purpose(s): {Note: “at the request of the patient” is sufficient of the patient is initiating the authorization}:

☐ The disclosure is at my (patient’s) request	☐Disability determination	☐Attorney/Legal investigation	☐ Personal use

☐ Further medical care	☐ Government agency/Police	☐ View medical records on site	☐ Insurance

I understand that once Carondelet Health discloses my health information to the recipient, Carondelet Health cannot guarantee that the recipient will not disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.

I understand that Carondelet Health may directly, or indirectly, receive remuneration from a third party in connection with the use and disclosure of my health information.

I understand that I may refuse to sign or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of my treatment at Carondelet Health; except, however, if my treatment at Carondelet Health is for the side purpose of creating health information for disclosure to the recipient identified in this Authorization, in which case, Carondelet Health may refuse to treat me if I do not sign this Authorization.

I understand that this Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of revocation to Carondelet Health’s Privacy Office at the address listed below. The revocation will be effective immediately upon Carondelet Health’s receipt of my written notice, except that the revocation will not have any effect on any action taken by Carondelet Health in reliance on this Authorization before it received my written notice of revocation.

I may contact Carondelet Health Medical Records Office by mail at:

St. Mary’s Hospital

c/o Medical Records

1601 W St Mary’s Rd

Tucson, AZ 85745

By telephone at: (520) 872-1088 or by email at: ROI@carondelet.org

I have read and I understand the terms of this Authorization and I have had an opportunity to ask questions about the use and disclosure of my health information. By my signature, I hereby, knowingly, and voluntarily authorize Carondelet Health to use or disclose my health information in the manner described above.

Signature of Patient	Date

Note: If patient is a minor or is otherwise unable to sign this Authorization, obtain the following signatures

Signature of Authorized Personal Representative	Date	Relationship to Patient

Identity of Requestor Verified via: ☐ Photo ID	☐ Matching Signature	☐ Other

Verified by:	Date:

Date Request Fulfilled:	By:

☐ Mailed	☐ Picked up by Patient	☐ Fed Ex

Records/Information Provided:

☐ Medical Record(s) for Date(s) Requested	☐ Billing Records	☐ Radiology CD	☐ Cardiology CD

☐	Other: