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It details required patient information, the reason for request, which protected health information categories may be released, optional initialed items, validity limits, and fees for copies not related to continuity of care.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/obtaining-or-requesting-medical-records-authorization-for-release-of-information-medical-records-revised-2025/283972/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/obtaining-or-requesting-medical-records-authorization-for-release-of-information-medical-records-revised-2025/283972.png","ImageObject",442,249,{"name":42,"@type":43},"Mabel","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-23","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",10,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information must be included in the first section of the authorization form?","Question",{"text":63,"@type":64},"Provide the patient’s name, date of birth, address, a telephone number where the patient can be reached, and the name/address/telephone and/or fax number of the person or facility where records will be sent.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How can I submit the completed medical records request and identification?",{"text":68,"@type":64},"Fax, email, mail, or drop off in person the completed request with a legible copy of a government-issued photo ID to M.H. S. Behavioral Services, Attn: Administration Department.",{"name":70,"@type":61,"acceptedAnswer":71},"How long is the authorization valid, and what happens if I do not initial certain items?",{"text":72,"@type":64},"The authorization expires 60 days from the authorization date unless otherwise noted on the form. HIV/AIDS status and related communicable items are released only if you initial next to those choices.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283972,1790443729,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":22},7971474920318,"https://ap-avatar.wpscdn.com/avatar/74000ee537e6b0ca360?x-image-process=image/resize,m_fixed,w_180,h_180&k=1788430171632181674","Tel: (702)848-1696 Fax: (702)463-7283  \n4000 S. Eastern Ave. Suite 240, Las Vegas, NV 89119  \nObtaining or Requesting Medical Records  \nPlease complete the following steps:  \n1. Complete the medical records \"Authorization for Release of Information\" form in its entirety.  \n2. Sign and date the form.  \n3. To verify your identification, we require that you include a legible copy of a valid Government issued photo ID (i.e.: driver’s license, military ID) .  \n4. Fax, E-Mail, Mail, Drop-off (in-person) your completed request along with your ID to:  \nM.H. S. Behavioral Services  \nAttn: Administration Department  \n4000 S. Eastern Ave. Suite 240  \nLas Vegas, NV 89119  \nP: (702) 848-1696 F: (702) 463-7283  \nE-Mail: [lcortez@mhs.com](lcortez@mhs.com)  \nInstructions for Completing the Authorization for Release of Information:  \nFirst Section please include the following information:  \n1. The patient’s name.  \n2. The patient’s date ofbirth.  \n3. The patient’s address.  \n4. Telephone number where the patient may be reached should we need to call you.  \n5. Name, Address, Telephone and/or Fax Number of person or facility where medical records are tobe sent.  \nSecond Section please include the following information:  \n1. Reason for request: Please explain why the requested protected health information is being requested.  \n2. Initial next to each choice of the protected health information to be released.  \no Please note: HIV and AIDS Status, and related disorders will ONLY be released if initialed.  \n3. Specify the dates of protected health information to be released. i.e.: dates the patient was admitted or in an Outpatient Program.  \n4. The date authorization is valid through. Authorization will expire in 60 days unless otherwise noted on the form.  \n5. Signature of patient/guardian. The patient’s signature is required unless the patient is a minor or has a legal representative. Proof of legal representation to act on behalf of the patient must be provided.  \n6. Date signed.  \n7. Please Note: Medical Records that are copied for any reason other than continuity of care are subject to a fee of $0.60 per page (NRS 629.061).  \nPlease allow 7-10 working business days from the date of receipt of the completed authorization. Nevada law permits up to 10 working days (NRS 629.061) . If medical records are needed for continuity of care MHS Behavioral Services will send the records to your provider at no cost to you.  \nDisability, Insurance, and Third-Party Requests: A request should be sent from Disability Determination Services, Social Security, your insurance company, or attorney and their fee will be billed to their office.  \nAuthorization for Release of Information (Medical Records)  \nRevised 2025  \nTel: (702)848-1696 Fax: (702)463-7283  \n4000 S. Eastern Ave. Suite 240, Las Vegas, NV 89119  \nPlease note: Medical Records copied for reasons other than continuity of care are subject to a copy fee of $0.60 per page (NRS 629.061) . If medical records are needed for continuity of care MHS Behavioral Services will send records to your Provider, unless the copy fee is paid. Complete, sign and date the form. To verify your identification and validate your authorization, we require you to include a legible copy of a valid Government issued photo I.D. (e.g., driver’s license, military I.D. or state I.D.) . Mail, fax (702-463-  \n7283) or personally bring your paperwork to MHS.  \nPATIENT NAME: __________________________________________ DATEOFBIRTH: ___________  \nADDRESS:___________________________________________________________________________  \nCITY, STATE, ZIP:   Last four (4) digits of Patient’s Social Security Number:   Clinician/Therapist:    \nTelephone number:    \nI hereby authorize Mingo Health Solutions to release [ ] OR obtain [ ] information/copies (check one) of protected health information from my mental health/substance abuse medical record to:  \nName of person, facility, and/or institution where medical records are to be sent or obtained:  \nAddr","cbCaig5XFexiid8R","https://ap.wps.com/l/cbCaig5XFexiid8R","pdf",181790,"English","# Obtaining or Requesting Medical Records\n## Steps to Submit the Request\n## Instructions for Completing the Authorization\n## Fees, Turnaround Time, and Continuity of Care\n## Disability, Insurance, and Third-Party Requests\n# Authorization for Release of Information (Medical Records)\n## Patient Information and Recipient Details\n## Protected Health Information Categories and Initialed Items\n## Consent, Validity, Rights, Revocation, and Redidisclosure Statement","[{\"question\":\"What information must be included in the first section of the authorization form?\",\"answer\":\"Provide the patient’s name, date of birth, address, a telephone number where the patient can be reached, and the name/address/telephone and/or fax number of the person or facility where records will be sent.\"},{\"question\":\"How can I submit the completed medical records request and identification?\",\"answer\":\"Fax, email, mail, or drop off in person the completed request with a legible copy of a government-issued photo ID to M.H. S. Behavioral Services, Attn: Administration Department.\"},{\"question\":\"How long is the authorization valid, and what happens if I do not initial certain items?\",\"answer\":\"The authorization expires 60 days from the authorization date unless otherwise noted on the form. HIV/AIDS status and related communicable items are released only if you initial next to those choices.\"}]","Obtaining or Requesting Medical Records - Authorization for Release of Information (Medical Records) - Revised 2025 | PDF",1789623609]