Medical Records Request and Release of Information

Release of information must comply with State and Federal guidelines. Please refer to the following Notice of Privacy Practices (pdf) for our complete policy. Please contact our Medical Records Clerk at 801-507-9555 if you have any questions regarding the release of patient information. After completing the online request form, please print the completed form and bring it to the office, fax the form to 801-507-9550, email it to forms@nsamd.com, or request records through our patient portal.

The form must be completed in its entirety in order to be valid. If you do not have a single, specific date which you would like records for, please indicate "all." If you would like records from other treating providers released to Neurosurgical Associates, LLC, and the other provider requires a written release, please complete the following form and submit it to the provider from whom you are requesting records.

To obtain copies of your own medical records, please complete the following form.

• Patient Request for Health Information

Medical Providers may request medical records for mutual patients over the phone or via fax. Please contact our office directly by phone at 801-507-9555 or via fax 801-507-9550.

Attorneys' offices may request medical records or account balance information for mutual patients with a current authorization on file. All requests for financial or medical records must be submitted in writing via fax to 801-507-9550. We will respond in writing and standard fees will apply. The fee for a balance inquiry is $15.00.

If you believe there is a mistake in your medical records, you have the right to request an amendment. Your request will be carefully reviewed and you will be notified of the outcome. Please complete the following form and submit it to our Medical Records Clerk for review and consideration.

• Medical Record Request for Review