Medical Release Form
To request medical records please download and print the
Return the form by doing one of the following:
- in person at 10631 S. 51st Street, Suite 8, Phoenix AZ 85044
- Fax to 480-398-4281
- email completed form to firstname.lastname@example.org
Releasing of medical records costs:
- First 10 pages are free/ calendar year
- Records over 10 pages costs $15.00 + .25/ page over 10 pages
- Records can be picked up in person (with identification) or mailed *certified mail.
- *Records mailed will be charged certified mail postage in addition to any processingfees.