Medical Records Request Authorization
ADVOCATE MDs MEDICAL RECORDS REQUEST AUTHORIZATION
I hereby authorize the release of my protected health information (PHI) to AdvocateMDs. This authorization is being provided voluntarily to facilitate physician-led medical advocacy, consultation, and coordination of care.
1. AUTHORIZED RECIPIENT
AdvocateMDs
Attn: Steven Morris, MD / Mark Rubin, MD
5635 N. Scottsdale Road
Suite 170- E2
Scottsdale, Arizona 85250
Phone: (480) 923-2376
Fax: (480) 944-7142
2. RECORDS TO BE RELEASED
I authorize the release of all medical records, including but not limited to: Physician Notes, Laboratory Results, Imaging Reports (X-ray, MRI, CT), Medication Records, and Hospital Discharge Summaries.
3. PATIENT RIGHTS & PRIVACY
- I understand I may revoke this authorization in writing at any time.
- I understand my records may no longer be protected by federal privacy laws once disclosed.
- This authorization expires one year from the date of signature.
Patient Name: ___________________________________
Signature: ___________________________________ Date: ____________________
Relationship to Patient: ___________________________________