Monday – Friday: 8:00 AM - 4:30 PM Saturday and Sunday: Closed Closed on Major Holidays
By signing this form, I authorize PEDIATRICS OF QUEEN CREEK to check one
PLEASE NOTE IT MAY TAKE UP TO 1-3 DAYS TO RECEIVE MEDICAL RECORDS
This authorization applies to the individual described above. Only the checked information will be disclosed in this authorization.
This authorization will expire 1 year from the date it was signed unless otherwise requested.
I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, AIDS or HIV, and alcohol and drug abuse. I authorize the release or disclosure of this type of information. I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization. The information released in response to authorization may be re-disclosed to other parties. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.
22707 S Ellsworth Rd, Suite H101 Queen Creek, AZ. 85142 (near Ellsworth and Ocotillo Rds)
Fax: (480) 792-9206
Monday – Friday: 8:00 AM - 4:30 PM Saturday and Sunday: Closed
Closed on Major Holidays
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