Name: Arizona Ketamine Treatment and Research Institute
Address: 2155 E. Conference Dr., Ste. 101, Tempe, Arizona, 85284
Telephone: (480) 626-2727

Authorization to Use or Disclose Protected Health Information

Information of Patient for Whom Authorization is Made

Name *

First

Last

Date of Birth *//

Phone *

Email *

Authorized Person to Disclose Protected Health Information

Doctor / Therapist Name *

Doctor / Therapist Address

Address Line 1

Address Line 2

City

State

Zip Code

Doctor / Therapist Phone

Doctor / Therapist Fax

Doctor / Therapist Email

The patient named above authorizes health information to be requested and released to representatives of:

Arizona Ketamine Treatment and Research Institute & Dr. Lauro Amezcua-Patino
Phone (480) 626-2727
FAX (480) 868-2272

Description of Information to be Disclosed (Please check one) *

All of my health information that the provider has in his or her possession including information relating to any medical history, mental or physical condition, and any treatment received by me.
Only the following records or types of health information:

Signature

By signing this form, I agree to the uses and disclosure of the information as described. *

Date//