To protect the privacy of our patients, SimonMed and its affiliates have instituted the following processes when requesting medical records:
- Complete the attached form: “Authorization to Release Protected Health Information”. Please complete all sections and sign and date the form.
- 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.
- 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.
- 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.