Emergency Contact:

Release of Medical Information:

I hereby authorize Sun Radiology to send or discuss my test results and other health related information on my behalf with the following individuals:

I also authorize Sun Radiology to send or receive my medical information to other providers requesting the information.
I authorize Sun Radiology to leave detail message via email, text message or voice mail about my appointments(current & future),lab and imaging results and other health related information.
I will notify Sun Radiology if there are any updates to above information.
I hereby acknowledge that I have received or have been given the opportunity to receive a copy of Sun Radiology P.C. notice of privacy practices. I understand that Sun Radiology participates in health current, Arizona’s health information exchange(HIE).I understand that my health information may be securely shared through the HIE unless I complete and return the Opt Out form to Sun Radiology.