"*" indicates required fields I hereby authorize* I hereby authorize use or disclosure of the named individual’s health information as described below.*Patient's Name* First Last Date Of Birth* Month Day Year Email Fax Number Send Records FromFacility/Physician Name* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone Number*Fax Number I hereby authorize and request the release of the following information* Last 3 visits, current labs, allergy testing, immunotherapy records and PFT's Patient Information for Visit Date(s) Other (specify) From* Month Day Year To* Month Day Year Specify Here* Send Records ToFacility/Physician Name* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone Number*Fax Number Terms and Conditions* I understand that once the healthcare provider provides the information that I am authorizing and requesting to be released to Third Parties, the healthcare provider has no control over the information provided to the patient or third parties. The individual or organization that I authorized to receive the information might disclose it or fail to ensure the information remains confidential and federal or state privacy laws may no longer protect the information. I agree that Arizona Allergy Associates is released from any and all liability or responsibility regarding information released to the patient or Third Parties pursuant to patient authorization to release such information.** This Authorization is valid for one year from the date of signature, and a copy of this Authorization is as valid as an original.*Effect of Refusing Authorization* If you refuse to sign this authorization, Arizona Allergy Associates will not deny you any treatment except research-related treatment.Signature* Type name for signature.Relationship to Patient Parent Guardian Only applies if the patient is a minor.Today's Date* Month Day Year Consent* By clicking submit I agree that I have read and will abide by all of Arizona Allergy Associates policies and that all information provided is accurate. Additionally, I acknowledge that this will serve as my electronic signature. Δ