Bella Women's Care fax number

Fax destination details

Department

Medical Records

Purpose

Medical records release / authorization to disclose PHI

Form

HIPAA Authorization to Use or Disclose Protected Health Information — Authorization to Use or Disclose Protected Health Information

Address

650 W Maryland Ave Ste 1, Phoenix, AZ 85013; 2204 S Dobson Rd Ste 202, Mesa, AZ 85202

Voice phone

602-240-2401; 480-633-6868

Website

Visit organization website

Before you send

• Confirm that this exact department handles your document or request.
• Check the organization website or call its main line for the current fax number.
• Include a cover sheet and any case, member, claim, or form reference required.
• Keep the delivery confirmation with your submission records.

Fill patient name and date of birth; designate the facility releasing records; designate the facility receiving records; check which records to release (office visits, lab results, diagnostics, prenatal/medical records, etc.); indicate reason for authorization (insurance purposes, further medical care, disability determination, attorney/legal investigation, etc.); sign and date; note that the authorization expires 90 days from signing.