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I authorize the named entity above (page 1) to use or disclose my health information in the manner described above. A description of the PHI that may be shared or disclosed.You MUST choose one of the following: I specifically authorize AHCCCS to disclose all of my protected health information in its possession. 6561 E. Carondelet Drive, Tucson, Arizona 85710. Direct access to PDF of HIPAA release. Free immediate download of PDF. Note: Government rules (HIPAA) require a separate form to share psychotherapy notes. Completed authorization forms can be faxed to (480) 728-9618. Mailing address: 3555 S. Mercy Rd., Gilbert, AZ 85297. Medical Records Department.