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About us
About APM
Dr. Lakshman Gollapalli – M.D.
Amalia Collins, PA-C
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Form upload
Exercise Guide
Understanding Pain
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ADVANCED PAIN MODALITIES AUTHORIZATION FOR USE OR DISCLOSE PROTECTED HEALTH INFORMATION (PFI)
3195 W RAY ROAD, SUITE 1
CHANDLER, AZ – 85226 PHONE: 480-756-6789
6750 E BROADWAY ROAD,
MESA, AZ – 85206
FAX: 480-246-8902
I authorize the disclosure of my protected health information (PHI):
Patient Name
Date of Birth
Address
City
State
Zip
Phone Number
Records Released From:
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Address
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State
Zip
Phone
Fax
Information to be Released: (Check all that apply)
Complete Medical Records
Billing Records
Treatment/Evaluation Records
Itemized Billin Statement
MRI/X-ray Imaging Reports
Lab Results
AIDS/HIV and other Communicable Diseases
Mental Health Information
Alcohol and or Drug Abuse Treatment
Genetic Testing Information
Other
By signing this form, I authorized the release of my confidential and protected health information to the entity listed above. I understand that I may revoke this authorization at any time, with written consent, unless this authorization has already been acted upon. This authorization will expire 1 year from the date unless otherwise noted or requested.
Patient's Name
Legal Representative Name
Date
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