SOL MEDICAL

Authorization for Release of Protected Health Information

Sol Medical

3118 W. THOMAS RD., STE 711 • PHOENIX, AZ 85017

PHONE: (602) 456-2821 • FAX: (602) 584-4924

Patient Name

Date of Birth

Address

Phone Number

To/From (requesting/receiving records)

Records to be released

By signing below, I authorize the release of Medical Records and Imaging Reports.

Authorization Terms

1. I may revoke this authorization in writing except to the extent already acted upon.

2. Not conditioned on treatment/payment/enrollment/eligibility.

3. Information disclosed may be re-disclosed and may no longer be protected.

4. Expires five (5) years from my signature date unless revoked earlier.

5. I am entitled to a copy of this authorization.

I accept and authorize Sol Medical to release the selected records as indicated above.

Signature

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Clear

Type your full name (as signature)

Date of Signature

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