SPA/VMH Client Records Request Form

Client Records Request Form
Date*

MonthDayYear
Date
Information Requested By:*

First NameLast Name
ROI must be on file if requested by someone other than client or legal guardian.
Date of ROI

MonthDayYear
Date
Relationship
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Information being requested*
Reason for request*
Copies to be made available by:*

Fax (If so, provide number below)Client Pick UpMail to address aboveReleased to provider for client reviewEmail (If so, provide email below)Other
Client Signature*

Clear
Signature Date*

MonthDayYear
Date
Please note, SPA/VMH policy states that all records requested may be reviewed by the provider(s) involved for information that may be harmful to the client. This information may or may not be included in the released file. SPA/VMH recommends that records be reviewed by client with the provider in order to review documentation and provide an opportunity for clarification of content.

Clients have the right to receive a free copy of their records one (1) time per calendar year. After that the following charges will apply:

$5.00 – Fax fee
$25.00 for first ten (10) pages
$.15 per page after that
PAYMENT IS DUE AND PAYABLE WITHIN 30 DAYS OF THIS BILLING. Please enclose a copy of this statement with payment.

Salem Psychiatric Associates and Valley Mental Health
821 Saginaw St South
Salem, Oregon 97302
Federal Tax ID: 93-0789808

$5.00 – Fax fee
$25.00 for first ten (10) pages
$.15/pp - # of pages___________

Total Amount Due: $___________
Should be Empty: