Telehealth Emergency Contact Release of Information Form

Please fill out the form below or download the Telehealth Emergency Contact Release of Information Form with the button above and fill it out at your convenience. Please email us if you have any questions. You can send completed paper forms to:

403 W. Cool Dr.
STE 107
Tucson, AZ 85704

or fax to:
520.329.8311

  • Assessing and evaluating threats and other emergencies can be more difficult when conducting telehealth than in traditional in-person services. To address some of these difficulties, we’ve created this release. The individual of your choosing will be identified as your emergency contact. This person should be near your physical location.

    Our doctors will only contact this individual to assist in addressing a crisis or emergency, as stipulated in the Informed Consent for Telehealth document.

  • as identified above, in the event of a perceived emergency or imminent threat to myself or to others. This authorization remains in effect until I submit a signed, written request to change the terms of this agreement.

  • Date Format: MM slash DD slash YYYY
  • **If signing on behalf of the patient, you must provide our office a copy of the Power of Attorney or proof of legal guardianship.

By clicking the submit button, you authorize the transmission of your personal health information to be sent over email. We take every effort to ensure that your information stays safe. All information is double encrypted and password protected.