You may use the below form to e-mail the University Clinics. The below form is not secure and is for non-medical questions or inquiries only. The form is not for emergencies. By using the below form, you acknowledge and agree use of this form does not establish a provider-patient relationship and the information provided is not covered by HIPAA or any other applicable privacy laws. If you have a healthcare-related question or any questions regarding patient care, please contact your provider’s office directly.
5855 Utopia RoadGlendale, AZ 85308
5865 Utopia RoadGlendale, AZ 85308
19389 N 59th AveGlendale, AZ 85308
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This authorization will expire 1 year from 10/24/2020.
I understand I may withdraw my authorization at any time by submitting a written request to the HIPAA Privacy Officer. I understand any revocation is not effective to the extent action has already been taken in reliance on this authorization. I understand information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by federal or state law. This authorization is not intended to affect a patient's ability to receive medical care.
Alcohol and Drug Abuse Treatment.
To the extent my medical record contains information regarding alcohol or drug treatment that is protected by federal law, I authorize the disclosure of such information or record.
HIV / AIDS Information
To the extent my medical record contains information regarding my HIV/AIDS status, treatment or testing, I authorize the disclosure of such information or record.
Behavioral Health Notes / Record
I authorize the disclosure of any behavioral health notes or information in my medical record.
With my digital signature below, I consent to the release of the above listed information / documents.
Community Partner site to email this completed form to firstname.lastname@example.org. Midwestern will
contact the patient to schedule an appointment within 48 business hours of receipt.