Medical Records Release Form

Please allow 5-7 business days for your request to be processed. For personal use of medical records, we recommend accessing through your online patient portal. Any obtaining of these records for personal use not through the portal are subject to a $25 fee. Requests sent to another medical office are not subject to fees.

If you have any questions, please feel free to contact our office at 435-215-0228.

Please click here to be directed to your Patient Portal.

example@example.com- To send you a copy of this form upon completion.

I request and authorize the named health care provider(s) (see page 2) to release the information specified below to theorganization, agency or individual named on this request. I understand that the information to be released may includeinformation regarding the following conditions(s) which may be protected by Federal Law, Drug/ Alcohol Abuse, MentalHealth Problems, Sickle Cell Anemia, HIV/AIDS Infection, Sexually Transmitted Diseases.

Confidential notice: The documents accompanying this release contain confidential information belonging to the sender. This
information is legally privileged and intended for the use of the individual named above, if you are not the intended recipient, please
notify the sender and dispose of the information you received. Use of this protected information by anyone other than the recipient
is strictly prohibited. The request will expire 12 months from signature date.

I hereby authorize Southwest Spine and Pain/Vista Healthcare to SEND my medical records to the organization/individual listed above at this time.I hereby authorize Southwest Spine and Pain/Vista Healthcare to RECEIVE records from the organization/individual listed above at this time.Do not send or request my medical records at this time but allow an open send/receive ability with this organization/individualOther

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