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155 W. Duval Rd. Green Valley, AZ 85614
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Authorization For Release of MEDICAL RECORDS
Progressive PT Green Valley
Patient Registration Forms
Authorization For Release of MEDICAL RECORDS
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Step
1
of 2
Name of Patient
*
First
Middle
Last
Patient Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Birth:
*
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Who are medical records being sent to?
*
Myself
Medical Facility / Law Office / HR Manager
How would you like to receive your medical recrods?
Email
Fax
Mail
Print
Email Address
*
CONFIDENTIALITY NOTICE: Email communication, including all attachments and related content, may contain private, confidential, or legally privileged information intended for the sole use of the designated and/or duly authorized recipient(s). Please note by signing below you acknowledge, you will receive your medical records in an unencrypted e-mail at your request.
I consent to receive my medical records in an unencrypted email at my request. Please Initial Below:
*
I consent to a charge of $.20/page. Please Initial Below:
*
You can pick up your Medical Records at the front office of Progressive Physical Therapy. Office Hours: M-F 8am-4.30pm
I consent to a charge of $.20/page. Please Initial Below:
*
Mail to Address Provided Above
*
Yes
No, a different address
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Fax Number
*
Name of Facility:
Facility Address:
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Facility Phone:
Facility Fax:
Facility Email:
CONFIDENTIALITY NOTICE: Email communication, including all attachments and related content, may contain private, confidential, or legally privileged information intended for the sole use of the designated and/or duly authorized recipient(s). Please note by signing below you acknowledge, your medical records will be sent in an unencrypted e-mail at your request.
Next
Please describe the records you are requesting. If applicable, include a date range and diagnosis. Please specify if you are also requesting billing records.
Electronic Signature
*
I understand an electronic signature constitutes a legal signature confirming I authorize the release of my medical records. Please send records to the address, email, or fax number above. A digital copy of the record release may serve as the original release.
Today's Date
*
Comment
Submit
Hours of Operation
Monday - Friday
8:00am - 4:30pm
Office Location
Progressive
Physical Therapy
155 W. Duval Rd.
Green Valley, AZ 85614
Phone: (520) 648-3132
FAX: (520) 648-1861
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