Revised Client Record Request Form

Solvista Health Client Records Request Form
Client Name*
DOB: *

MonthDayYear
Date
Age
Client ID
Person Making Request*
Relationship to client
Reason for Request*
Phone*
Records Request Timeframe: Start Date:*

MonthDayYear
Date
Records Request Timeframe: End Date:*

MonthDayYear
Date
Open case with DHS

YesNo
Please Check the box next to the information you are requesting: Behavioral Health

Intake AssessmentPsychiatric Appointment NotesMedication ListDischarge SummaryIndividual Therapy NotesFamily Therapy NotesGroup Therapy NotesCurrent Treatment PlanCase ManagementEntire Clinical RecordOther
Primary Care and Medication Assisted Treatment

Office Visit NotesLabs and ImagingEntire Medical RecordOther
Regional Assessment Center (RAC)

Entire Clinical Record - must specify date range:IntakeDischarge SummaryOther
Additional Requests:

Administrative Forms and LettersSigned Releases of Information FormsCare Coordination
How I would like to receive the information:
I will pick up the chart-please call me at
Mailed to the following address
Electronic-sent to the following email
example@example.com
Other (Please Describe)
I understand that I may be denied access to my record if a licensed clinician, in using their professional judgement, decides that providing the record may endanger my, or another person's life or physical safety, or for other reasons allowed by law. Some, but not all, decisions to deny access may be reviewed. If my request is denied, Solvista Health will inform me in writing, and explain the reasons for denial, and describe any review process. Please allow 30 days to process this request.
Client or Representative Signature*

Clear
Today's Date*

MonthDayYear
Date
Staff Processing Request Print
Staff Processing Request Signature

Clear
Date

MonthDayYear
Date
Form of Delivery/Date/By Whom
Individual's Right to Access-Effective 09/01/2016; Revised

4/25/24 by Medical Records Department
Should be Empty:

How I would like to receive the information: