Note: In the event that the facility is unable to accommodate an electronic delivery as requested, an alternate delivery method will be
provided (e.g.; paper copy). There is some level of risk that a third party could see your PHI without your consent when receiving
encrypted media or email. We are not responsible for unauthorized access to the PHI contained in this format or any risks (e.g.; virus)
potentially introduced to your computer/device when receiving PHI in electronic format or via email.
Please upload a picture ID
Please upload a valid ID (Driver's license, passport, state issued ID)
Protected Health Information (PHI) can be released to the following:
Please complete one for each individual/company you would like your records released to. More fields will appear as you complete each section.
I understand that:
1. Upon completion of a visit, corroborating medical records are automatically forwarded to the
referring physician.2. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this
authorization. I can refuse to sign this form, as it is voluntary.
3. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on actions
taken prior to receiving the revocation. Further details can be found in the HIPAA notices.
4. If the requester or receiver is not a health plan or healthcare provider, the released information may
no longer be protected by federal privacy regulations and may be re-disclosed.
5. Medical records copied for reasons other than continuity of care are subject to a copy fee (NRS
629.061). These include but are not limited to legal requests, investigative agencies, insurance
companies, and patient personal use requests. Multiple copies will be charged for.
6. CHC will take precautions to avoid improper access to PHI but I acknowledge that if I lose the CD
and/or password, they are stolen from my possession, or if I allow another person access to the
CD/password, CHC will not be liable for any resulting unauthorized access under any circumstances.
7. I am aware that if medical notes are requested, the mental health notes are not automatically
released and are in fact kept separate from all other clinic notes.
8. This PHI is in fact null and void without the signature of the patient (if 18 or older), parent or legal
All items on this authorization form must be completed or request may not be honored.
I have read the above and authorize the disclosure of the protected health information as stated:
3131 La Canada St., Ste. 230
Las Vegas, NV 89169
Phone: (702) 732-1920
Toll-Free: (866) 732-1290
Fax: (702) 732-1385
85 Kirman Ave, Ste. 401
Reno, NV 89502
Phone: (775) 324-6644
Toll-Free: (877) 732-1290
Fax: (702) 322-4748