Authorization for Release of Medical Records


Desert River Solutions

600 W. Ray Road Suite C-2

Chandler, AZ 85225

 

Your Full Address:

     

 

Requesting From (Name of Doctor or Medical Office):   

 

I authorize Desert River Solutions to SEND medical records TO THE FOLLOWING and by the FOLLOWING OPTION:

Send To (Name):  

Address:

Email Address On Where to Send To:   

 

  authorize the release of information related to AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) infection, psychiatric care and/or psychological assessment and treatment for alcohol and/or drug abuse.

 

I authorize the release of an electronic version of my medical records in the possession or control of the above named provider/clinic/hospital; its employees and agents.

Please provide Relationship To Patient if You are NOT the Patient 

Leave this empty:

Desert River Solutions http://desertriversolutions.com
Signature Certificate
Document name: Authorization for Release of Medical Records
Unique Document ID: 8e21fc49ffe34dd72754176fe22f48ddda11c806
Timestamp Audit
April 26, 2018 8:24 am MSTAuthorization for Release of Medical Records Uploaded by Andrew Szmuc - [email protected] IP 70.184.127.222, 162.158.142.33