Permission Form

We have various medical documents we require parents/guardians to read and sign. These documents and the required forms for signature are below. Thank you in advance!

HIPAA Consent
The Health Insurance Portability and Accountability (HIPAA) requires us to provide you with notice of our privacy practices. The goal is to protect your privacy and rights. Your typed signature indicates that you have received and reviewed the notices described and consent to treatment.

Authorization for Disclosure of Health Information
1. I authorize the use or disclosure of the above named individual`s health information as described below.
2. The following individual or organization is authorized to make the disclosure.
3. The type & amount of information to be disclosed
4. I understand that the information in my health record may include information relating to sexually transmitted disease, Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.
5. This information may be disclosed to and used by the following individual or organization.
Name: Mariposa Community Health Center
Address: 1852 N. Mastick Way
City: Nogales State: Arizona Zip: 85621
Phone: (520) 281-1550
Fax: (520) 281-4487 (Adult)
Fax: (520) 375-6013 (Pediatrics)
6. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Medical Information Department. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy, unless otherwise revoked.

7. If I fail to specify an expiration date, event or condition, this authorization will expire in sixty days. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR164, 524. I understand that any disclosure of information carries with it the potential for any unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact Mariposa’s Privacy Officer.
* Please note that by entering your name below, this electronic signature will serve as your legal written signature.

Welcome to Mariposa Community Health Center
Thank you for allowing us to care for you.
Preferred Language
Gender
Phone Numbers are Very Important to Us!
Insurance Information
No Insurance?
This section is to enroll in our patient portal.
Registered?
Preferred Pharmacy (select up to two)

Mariposa Your Community Health Center
As a Community Health Center, we are required to request the following information from you. The data we receive is released in summary form, for collection purposes only. No patient names are associated with any released data
Housing Information
Do any of the following apply to you?
Are you a veteran?
Select the box or boxes that describe your race:
Are you Hispanic or Latino?
What is the primary language spoken at home?