• Fill out each section of the “Authorization to Release Protected Health Information” form.
• You may choose to pick up your medical record by hand carrying the form to any SimonMed Imaging center, or you may submit the form via email or fax and have your medical record sent to you..
  1. Email: Please email the completed “Authorization to Release Protected Health Information” and a photo copy of your valid ID to [email protected]. All requests will be expedited as quickly as possible (no longer than 30 days).
  2. Fax: Please fax the completed “Authorization to Release Protected Health Information” and a photo copy of your valid ID to fax # (602) 302-5958. All requests will be expedited as quickly as possible (no longer than 30 days).
  3. Hand Carry/Pick up: Please take the completed “Authorization to Release Protected Health Information” form with a valid ID to any SimonMed Imaging center. Please note, wait times may vary for walk-in requests.

Please note: A fee of $50.00 per set applies for any film request. As a courtesy to our patients, any request for reports and/or a CD containing images will be provided at no charge. If the “Authorization to Release Protected Health Information” form is incomplete, you will be contacted by a Medical Record staff member to request additional information.

• Direct to Provider. The easiest method is for SimonMed to send your medical records directly to your medical provider please indicate either by fax or email in the “Requesting” section. If the medical provider is capable of receiving medical records electronically, SimonMed reserves the right to send records by secure electronic means. Submit the “Authorization to Release Protected Health Information” form via fax with a photo copy of your valid identification to fax # (602) 302-5958 or email to [email protected].