Secure Medical Records Request Form

Please use this secure form for personal medical records requests only. Whenever possible, direct physician-to-physician transfer of medical records remains the preferred method for continuity of care.

To help avoid processing delays, please complete all requested information below. By submitting this form and typing your name below as your electronic signature, you authorize the release of medical records requested below.

Please do not use this for medical emergencies, appointment requests, or urgent medical concerns. If you are experiencing a medical emergency, call 911 or seek immediate medical attention.

All submitted information is transmitted securely and encrypted during delivery.

Patient Full Name

Date of Birth

Phone Number

Email Address

Mailing Address (required for records processing and correspondence)

Requestor Information - I am requesting records as

Patient Parent or Legal Guardian Other

Printed Name of Requestor (if not patient):

Relationship to Patient:

If you are requesting records on behalf of another individual, additional authorization or legal documentation may be required before records can be released.

Requested Records

Please select one option below and provide additional details where applicable.

Complete Medical Record Records From Specific Date Range Specific Records

Complete the date fields below only if requesting records from a specific date range.

Use the description box below only if requesting specific records (labs, radiology, immunizations, etc.)

Records Requested From:

Records Requested To:

Please describe the specific records requested.

Sensitive Information Authorization Please select any specially protected information you authorize for release as part of your medical records request

Mental health or behavioral health information

HIV/AIDS-related testing or treatment information

Alcohol or substance use treatment information

Other sensitive or specially protected health information contained in the medical records

By initialing below, I acknowledge that I am authorizing the release of any sensitive or specially protected health information selected above, if contained within my medical record.

Patient Initials

Requested Delivery Method

Please Select One Delivery Option Below:

Secure Electronic Encrypted Portal Access Printed Paper Copies by Mail Unencrypted Email (Not Recommended)

Secure Electronic Delivery / Patient Portal Access

Patients selecting secure electronic delivery will receive instructions and a secure portal access link by email after processing the request. When available, patients may also have the option to use existing Apple or Google account credentials to access the secure portal. Patients are encouraged to download and save their records after notification that records are available, as secure access links may expire.

Fees

Printed paper copies requested by mail will be subject to copying fees of $0.60 per page, plus applicable postage and mailing costs, consistent with Nevada law and applicable medical records guidelines.

Unencrypted Email Delivery Acknowledgment

I understand that unencrypted email delivery may carry privacy and security risks, including the possibility that medical information could be intercepted or accessed by unauthorized individuals during electronic transmission. I also understand that some email providers may limit attachment sizes, which could restrict the amount of medical records that may be sent electronically through this method.

Patient Initials

By entering my initials above, I acknowledge and accept the risks associated with unencrypted email delivery of medical records.

If you are unable to complete this form electronically, printed and signed authorization forms are available for download at our website twfmlasvegas.com or by emailing twfmrecords@hushmail.com.

Authorization and Signature

By submitting this form, I acknowledge that I have read and understand the information provided on this authorization form and authorize the release of the medical records requested above. To help avoid delays in processing, please ensure this authorization form is signed and dated before submission.

By typing my name below and submitting this form, I acknowledge and agree that my typed name serves as my electronic signature.

Typed Full Name (Electronic Signature)

Date Signed

Your information will be encrypted.