Center for Respiratory and Sleep Disorder

Release & Records

Gilbert Respiratory Associates


3491 S. Mercy Road Ste #103
Gilbert, AZ 85297
Phone: (480) 917-0933         Fax: (480) 917-8866

Release of Information
   



   PHONE 






FOR CONTINUED PATIENT CARE - FAX INFORMATION TO: ATTENTION

  DR. JEHAD BAYASI       DR. VIRGINIA ROWLAND

COPIES OF:   DICTATION   LAB  XRAY/CT/MRI  EKG/Echo    PFT

 OTHERS: 


I hereby authorize  to provide Gilbert Respiratory with a copy of any and all records, documents, reports, including HIV information, clinical abstracts, histories and charts of every kind and description, as indicated above, relating to my treatment and care during above described treatments date(s).

It is understood this consent is subject to revocation at any time except to the extent that action has been taken in reliance thereon. In the absence of express revocation, this consent shall expire in ninety (90) days from the date of signature. In furtherance of this authorization, I hereby waive all provision of law any privileges relating this disclosures authorized.




(Patient signature/Legally Authorized Representative)
 
(Date)
     
If patient is unable to consent by reason of age or some other factor(s), state reason and relationship.





(Witness Signature) if signed by legal authorized representative
 
(Date)
     
Information is from confidential records, which are protected by State law that prohibits further disclosure of the information without specific written consent.