REQUEST TO ACCESS PROTECTED HEALTH INFORMATION ( PHI ) NOTE : Please complete all fields to prevent delays in our response
Patient Name : ___________________________________________________________ Birth Date : ________________
Printed ( First ) ( MI ) ( Last Name )
Address : ________________________________________________________________ Telephone #: ______________
Street Address City State Zip Code
I request that : Renown Health ( circle one ) SEND TO -or- RECEIVE FROM the below entity :
_______________________________________________________ Telephone #: _____________ Fax : _____________ Full Name / Entity
Address : ___________________________________________________________________________________________
Street Address City State Zip Code
For Date ( s ) of Service from : ________________________ to ________________________ [ Dates MUST be specified ] Information To Be Disclosed : ** Unless item is marked below it will not be disclosed **
□ Entire Medical Record ( All records in the Designated Record Set ; includes billing and radiology films / CDs )
□ Other ( please specify ): ______________________________________________________________________________
Format Records Are To Be Disclosed :
□ Paper copy
□ CD with password encryption
□ PDF ( Upload to Renown Epic MyChart Account )
□ Other ( please specify ): ____________________
Record Delivery
□ Mail to the address listed below
□ Fax to the address listed below
□ MyChart ( PDF upload only )
□ For pick-up , call 775-982-2790
I UNDERSTAND THAT :
● This Request is effective immediately .
Signature of PATIENT ONLY :____________________________ Print Name :___________________ Date :___________
Signature of Person Who Is NOT the Patient :____________________________________________ Date :___________ Print Name : __________________________________ Authority to Sign : _____________________________________
Proof of Authority MUST be attached ( except for parents )
Address : ____________________________________________________________________ Tel No : _______________
*** Completed by Staff Member Fulfilling & Verifying Request & Completeness *** Date : ________________ Time : ___________ Verified By : ____________________________________________________
MR #: ___________________________________
Account #: ____________________________________________________ List Document Used to Verify ( attach a copy ): _________________________________________________________________________________ Provider Signature for Release of Psychiatric / Mental Health Records : ______________________________________________________________ Printed Provider Name : __________________________________________________________ Date : __________________________________
1155 Mill St . Mail Code O12 Reno , NV 89502 Fax : 775-982-3759
□ Tracking only / Records released
□ Mail
□ Patient Pick-up at Renown Regional
Form Number : 100-467 Revision Date : 6 / 2023