Medical Records Request

Protecting Your Privacy

Your privacy matters to us. Mountain Park Health Center ensures that your medical records are only accessible to you, your healthcare providers, or individuals you authorize.

Requesting Health Records

To release your health records to you or a third party you approve, please complete the Authorization to Release Information form. Filling out the form completely helps us process your request accurately.

Processing Time

Please allow up to 15 business days for your request to be completed. Mountain Park follows all legal requirements for maintaining and releasing medical records.

How to Submit Your Request

You can submit your completed form in any of the following ways:

Online: Fill out the form below to submit your request online!

Email: Send to HIMS@mphc-az.org

Fax: Attention Health Records at 602-323-8199

In Person: Hand-deliver to the front desk at any Mountain Park clinic location.

Questions?

If you have questions about your request, contact our Health Records Department at 602-243-7277.

Mountain Park Health | Medical Records Request

Authorization to Release Patient Information

Use this form to authorize the release or receipt of your health information. Please complete all required fields.

Patient Full Name
MM slash DD slash YYYY
Address
Authorization Type
Address
Purpose of Information Release

MM slash DD slash YYYY
MM slash DD slash YYYY
Type of Records Requested
Delivery Method

By completing and submitting this form, I understand and agree to the following:

Right to Cancel:
I understand that I have the right to cancel this authorization at any time. If I choose to cancel, I must do so in writing and submit my request to the Medical Records Department via fax. I understand that cancellation will not apply to information that has already been released in response to this authorization.

No Condition of Treatment:
I understand that Mountain Park Health Center will not condition or deny treatment, payment, enrollment in a health plan, or eligibility for benefits based on whether or not I sign this authorization.

Authorization Expiration:
This authorization will expire on the date, event, or condition specified elsewhere in this form. If no expiration is specified, I understand that this authorization will automatically expire in 90 days.

Sensitive Health Information:
I understand that this authorization may include disclosure of sensitive health information, including HIV/AIDS, sexually transmitted infections, behavioral or mental health treatment, substance or alcohol abuse treatment, and/or genetic information.

Redisclosure Notice:
I understand that once my health information is disclosed, it may be subject to redisclosure and may no longer be protected by federal confidentiality regulations.

Voluntary Authorization:
I understand that authorizing the disclosure of my health information is voluntary and that I may refuse to sign this authorization.

MM slash DD slash YYYY
Consent Acknowledgement
Clear Signature