Tucson Medical Center 5301 E Grant Rd , Tucson, AZ 85712-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the name of the individual authorized to disclose protected health information (PHI) in the designated field.
3. Fill in the patient’s name and date of birth accurately to ensure proper identification.
4. Provide the patient's address and phone number for contact purposes.
5. Enter the patient medical record number or any other identifiers that may be required.
6. Specify the date range for which PHI is being requested and indicate where this information should be sent.
7. Select specific types of information to be disclosed by checking the appropriate boxes, such as discharge summaries or lab tests.
8. Clearly state the purpose for this disclosure by selecting from provided options or specifying your own reason.
9. Sign and date the authorization at the bottom of the form, ensuring all necessary fields are completed before submission.

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