Authorization for the Release of Medical Records
For the purpose of continued treatment and billing/re-assignment of benefits, this allows AZOPT to bill on your
behalf, and for the payment to be sent directly to AZOPT, to:
Arizona Orthopedic Physical Therapy, PLLC
14557 W. Indian School Rd. #500
Goodyear, AZ 85395
Notice of Privacy Practices
Your name and signature below indicate that you have received a copy of and/or have been directed to the
Notice of Privacy Practices by Arizona Orthopedic Physical Therapy, PLLC, on the date indicated. If you have any questions regarding the information set forth in AZOPT’s Notice of Privacy Practices, please do not hesitate to ask an AZOPT representative.
Photo Consent Release
in publications and advertisements produced by or for AZOPT. I understand that these publications will also
be placed on websites managed by AZOPT for public relations and advertising purposes. I understand that
the publication may appear on the Internet, the publication may appear in print, electronic, or video media, and
the publication may enable readers to identify me. I understand this consent is valid until I provide written
notice stating otherwise.