HIPAA Authorization - Arizona

Arizona · Fillable PDF · Free

This form lets doctors, hospitals and health plans share your medical information with family members or others you choose. It does not let them make decisions for you; for that, use a Health Care Power of Attorney. This form lets doctors, hospitals and health plans share your medical information with family members or others you choose.

Serving Arizona. Appointments require an Arizona-commissioned notary.

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Who this form is for

This form lets doctors, hospitals and health plans share your medical information with family members or others you choose. It does not let them make decisions for you; for that, use a Health Care Power of Attorney.

What you'll need

The original HIPAA Authorization - Arizona packet and its instructions.
Names, dates and supporting records identified in this packet.
Acceptable identification for any notarial act; arrange qualified witnesses when required.

How to complete it

Choose who may release information All of your providers, or only the ones you list.
Name up to three people Each person may receive information separately.
Choose what may be shared Mental health, substance use, HIV and genetic records are shared only if you initial them.
Sign it, and notarize it if needed Many insurers and out-of-state providers prefer a notarized authorization.

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These forms are a free convenience, not legal advice. First Choice Mobile Notary & Apostille is not a law firm. Consult an attorney licensed in the relevant state for legal questions.

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