1. The above identified individual, authorize NATIVE AMERICAN COMMUNITY HEALTH CENTER, Inc. and the following facilities:
Native Health Behavioral Health — Central 4041 N. Central, Bldg C Phoenix, AZ 85012 (602)279-5262 (602)279-5393(fax)
Native Health Behavioral Health - West 2423 W. Dunlap #140 Phoenix, AZ 85021 (602)279-5351 (602)279-5361(fax)
Native Health Behavioral Health — Mesa 777 West Southern Ave., Bldg E, Ste 501, Mesa, AZ 85210 (480)550-4048 (480)264-5099(fax)
To release / obtain medical information from my medical record to / from:
Notice to Recipient: you are receiving this information, from records that are private, confidentiality and protected by Federal law. Federal regulations (42CFR Part 2 and 45 CFR Section 164) prohibits you from making any further disclosure of it without this specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose.