Securing your medical records

Request for Medical Records Form

  • The Health Insurance Portability and Accountability Act (HIPAA) dictates that personal medical records can ONLY be released to the patient or the patient’s parent or legal guardian. However, Northern Arizona Healthcare may release patient records for further treatment of the patient, for payment by insurers and for quality studies within our facilities.
  • Medical record requests require a signed “Authorization to Disclose Protected Health Information” form and a photo I.D. This enables us to validate that the request is authentic.
  • On this form, be sure to list the appropriate service dates, and check all the specific records you require.
  • If your records include information about AIDS/HIV, psychiatric care or alcohol/drug abuse care, you must specifically indicate you are authorizing these records to be released by noting this in the “Authorization to disclose information” section of the form.
  • Items such as radiology images, photos and telemetry tapes are not a part of the medical record. If you need these items, please contact the specific departments directly.
  • Cost of obtaining medical records: Ten pages of information are available to patients each year without charge. Most other requests will incur a minimal fee. Fees are waived for information sent directly to another healthcare provider.
    • Payments may be made with cash, checks or credit cards; payments must be made when records are received.
    • Note that requests for sending information to another healthcare provider are our top priority. Please allow two to three weeks for routine tests to be processed.
  • "Authorization to Disclose Protected Health Information" forms can be faxed, mailed or brought to the Health Information Management departments at any of the NAH facilities listed below.

Contact Information

Health Information Management – Flagstaff Medical Center
Medical Record Requests 
1200 N. Beaver St.
Flagstaff, AZ 86001
Phone: 928-773-2072
Fax: 928-773-2178


Health Information Management – Verde Valley Medical Center
Medical Record Requests 
269 S. Candy Lane
Cottonwood, AZ 86326
Phone: 928-639-6280
Fax: 928-639-6030