Medical Records Request

Medical Records Request – Important Notice

PLEASE READ CAREFULLY BEFORE SUBMITTING THIS FORM

This form is strictly limited to requests for records related to psychotherapy services provided directly through Well-beings AZ LLC.

By submitting this form, you acknowledge and agree to the following:

1. Scope of This Form

This form does not process, transmit, or forward records requests for services provided through third-party platforms.

This form is used only for records maintained by Well-beings AZ LLC in its capacity as the treating provider and custodian of record.

2. Platform-Specific Records Custody

Records are maintained by the entity through which services were rendered, as follows:

• Well-beings AZ LLC
  → Records requests may be submitted through this form, only with a valid, signed Release of Information (ROI).

• SonderMind
  → Records are maintained by SonderMind.
  → Requests must be submitted directly to SonderMind.

• Spring Health
  → Records are maintained by Spring Health.
  → Requests must be submitted directly to Spring Health.

• Headway (services provided on or after January 1, 2026)
  → Records are maintained within the Headway platform.
  → Requests must be submitted through the Headway client portal.

Well-beings AZ LLC does not have custody, control, or release authority over records maintained by third-party platforms and cannot access, release, amend, or transmit such records on a requester’s behalf.

3. Release of Information (ROI) Requirement

For requests related to Well-beings AZ LLC, a completed, signed, and valid Release of Information (ROI) is required prior to any disclosure.

Requests submitted without a valid ROI will not be processed.

Requests submitted with an invalid, incomplete, expired, or improperly executed ROI will be rejected without further action.

4. Unauthorized or Misrouted Requests

Requests submitted through this form for records maintained by SonderMind, Spring Health, or Headway:

• Will not be processed

• Will not be forwarded

• Will not be responded to beyond this notice

Misrouted submissions do not establish a duty to act, investigate, or transfer records.

5. HIPAA & Legal Compliance

All disclosures are governed by:

• The Health Insurance Portability and Accountability Act (HIPAA)

• Applicable Arizona law

• Professional standards set by the Arizona Board of Behavioral Health Examiners (AZBBHE)

Records requests will be fulfilled only to the extent permitted by law and within legally required timeframes following receipt of a valid ROI.

6. Emergency & Clinical Contact Disclaimer

This form is not monitored for emergencies, urgent clinical concerns, or crisis situations.

If you are experiencing an emergency, contact 911, go to the nearest emergency department, or contact the 988 Suicide & Crisis Lifeline.

7. Acknowledgment

By submitting this form, you acknowledge that:

• You have read and understood the limitations of this form

• You understand that records custody is platform-specific

• You understand that improperly submitted requests will not be processed