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Medical Records Policy

Simon Med Authorization To Release

To protect the privacy of our patients, SimonMed and its affiliates have instituted the following processes when requesting medical records:

  1. Complete the attached form: “Authorization to Release Protected Health Information”. Please complete all sections and sign and date the form.
  2. Direct to Provider. The easiest method is for SimonMed to send your medical records directly to your medical provider please indicate either by fax or mail in the “Requesting” section. If the medical provider is capable of receiving medical records electronically, SimonMed reserves the right to send records by secure electronic means. Submit the “Authorization to Release Protected Health Information” form via fax with a photo copy of your valid identification to (602) 302-5958.
  3. Fax Request / Direct to Patient. You may submit the request via fax and have your medical record sent to you. Please fax the completed “Authorization to Release Protected Health Information” form and a photocopy of your valid identification to (602) 302-5958. All requests will be processed within 1 week of request receipt.
  4. Collect in Person.You may pick up your medical records by hand carrying the form and a valid identification to any SimonMed Imaging center. You may experience a short wait to print and process your request.

Please note: A fee of $25.00 per set applies for any film request. As a courtesy to our patients, any request for reports and/or a CD containing images will be provided at no charge. If the “Authorization to Release Protected Health Information” form is incomplete, you will be contacted by a Medical Record staff member to request additional information.

To receive your medical record, please complete the following steps in their entirety

  1. Fill out each section of the “Authorization to Release Protected Health Information” form.
  2. You may choose to pick up your medical record by hand carrying the form to any SimonMed Imaging center, or you may submit the form via fax and have your medical record sent to you.
    1. Hand Carry/Pick up: Please take the completed “Authorization to Release Protected Health Information” form with a valid ID to any SimonMed Imaging center. In certain circumstances, you may experience a wait of up to 15 minutes to process your request.
    2. Fax: Please fax the completed “Authorization to Release Protected Health Information” and a photo copy of your valid ID to (602) 302-5958. All requests are processed within 1 week of receipt.

Please note: A fee of $25.00 per set applies for any film request. As a courtesy to our patients, any request for reports and/or a CD containing images will be provided at no charge. If the “Authorization to Release Protected Health Information” form is incomplete, you will be contacted by a Medical Record staff member to request additional information

Authorization to Release Protected Health Information
PLEASE FILL OUT EACH SECTION BELOW

To Disclose My Records:(Please check the exam(s) for which you are requesting reports/images)
Are you requesting (check all that apply):
Please note, a $25.00 fee per set of films and CDs are promptly prepared at the time of pick up.
Please indicate how you would like these to be received:
I understand that my records will only be provided to myself or any individual(s) I listed below. A photo ID is required at the time of pickup
By my signature below, I authorize SimonMed Imaging to release my protected health information to the following individual(s):
I understand that after the custodian of records discloses my health information, it may no longer be protected by federal and/or state privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment, payment, eligibility for benefits unless allowed by law. I understand this authorization maybe revoked in writing at any time, except to the extent that action has been taken in reliance on the authorization. Unless otherwise revoked, this authorization will expire 1 year from date of signature. You have the right to revoke this authorization,except to the extent the custodian of records has relied on it, by sending your written request to the Privacy Officer at: 6900 E. Camelback Road, #700 Scottsdale, AZ 85251
Patient or Authorized Representative Signature
Date of Signature
Printed Name of Patient or Authorized Representative
Relationship to Patient
Phone: (866) 614-8555
Fax (602) 302-5958
FM.HIM001
UPDATED: 08/14/2014


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Why Choose Us

SimonMed Imaging and its affiliates have been serving the community for over 30 years. Our mission is to provide best-in class affordable care through the use of advanced technology. We have patient-focused staff and highly trained medical professionals.


SimonMed has over 100 convenient locations and provides late night and weekend appointments to accommodate patients.

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