Patient Record Request 2023

PATIENT RECORDS REQUEST

This request is to be filled out by the patient in order to receive their records through our secure portal online.
Today's Date

MonthDayYear
Date
Patient Name*
DOB*
Phone*
I am requesting my records from date of service

MonthDayYear
Date
To date of service

MonthDayYear
Date
Or one date of service

MonthDayYear
Date
All records including medications will be sent by secure message through our MIYO portal. If help logging into our portal is needed, please reach out to our main line at 928-985-1495. Expect this process to take 30 plus days for approval and processing. Your provider's schedule as well as the complexity of the records being requested will affect the time if takes for your request to be processed. We are grateful for your understanding and patience.
Patient Signature (If under 18 a parent or legal guardian may sign)*

Clear
914 N San Francisco St. Ste. D, Flagstaff AZ 86001

PH 928-985-1495 Fax 928-597-5198
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