• AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

  • Breakthrough Medicine - 702 S Main St, Cottonwood AZ 86326 - P: 928-649-0269 | F: 866-644-6363

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  • to disclose protected health information of the person listed above, to:

    Breakthrough Medicine - FAX (866) 644- 6363

    1. I acknowledge, and herby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV results or AIDS information.
    2. I understand that this authorization may be revoked by me at any time except to the extent that action has been taken in reliance upon it.
    3. The information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer protected.
    4. I understand that there may be a fee involved with the fulfillment of this request.
    5. I understand that the term, entire record, regarding release of protected Health Information means that only records generated by the named facility will be released.
    6. I have read the above and authorize the disclosure of the protected health information.
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