Southwest Urologic Specialists, P.C. fax number

Fax destination details

Department

Medical Records

Purpose

Authorization for Disclosure of Patient Health Care Information; record release

Form

Authorization for Disclosure of Patient Health Care Information — Authorization for Disclosure of Patient Health Care Information

Address

6007 E Baseline Rd, Suite 105, Mesa, AZ 85206

Voice phone

(480) 897-2727

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; provide address; indicate which records to release (complete records, lab reports, X-rays/imaging, office notes, pathology); designate recipient; sign and date; if someone else signs, specify the relationship; form expires after one year unless otherwise stated; for HIV/AIDS, sexually transmitted disease, psychiatric/mental health, or drug treatment information, additional consent may be required.

Official form instructions are published as a downloadable file on the organization's website.