How to request a copy of your Medical Records
Request for Medical Records Form
- As part of the Health Insurance Portability and Accountability Act (HIPAA) records may be released without authorization for reasons related to further treatment of the patient, for payment by insurers, and for operational reasons such as quality studies within our facilities. These records are released only to the patient, parent, or legal guardian.
- Medical records requested for reasons other than treatment, payment, or operations require a signed “Authorization to Disclose Protected Health Information” form and a photo ID that allows us to validate the request is authentic.
- To request a copy of your records please print and complete the “Authorization to Disclose Protected Health Information” form indicating the dates of treatment for which you are requesting information.
- If your records include information about AIDS/HIV, psychiatric care, or alcohol/drug abuse care you must specifically indicate that you are authorizing these records to be released by noting this in the “Authorization to disclose information” section of the form.
- Items such as Radiology images, photos, and Telemetry tapes are not a part of the medical record. If you need these items, please contact the specific departments directly.
- Cost of obtaining medical records - Ten pages of information are available to patients each year without charge. Most other requests will incur a minimal fee. Please call the Health Information Management department at Verde Valley Medical Center at 928 639-6280 or Flagstaff Medical Center at 928 773-2072 for additional information. Fees are waived for information being sent directly to another medical care provider.
- Requests for information to go to another medical facility or physician office are top priority and completed within the time frame requested. Please allow two to three weeks for other routine requests to be processed.
- Payments for copies must be paid at the time copies are picked up or when received by mail. We reserve the right to request pre-payment for copies. Cash, checks, and credit cards are accepted for payment.
- "Authorization to Disclose Protected Health Information" forms can be faxed, mailed or brought to the Health Information Management departments at any of the NAH facilities. Address information is listed on the bottom of this Web page.
- Fax numbers:
- Flagstaff Medical Center Health Information Management
- Verde Valley Medical Center Health Information Management