• Record Request Form

    Harmony Mental Health Inc. [HMH]

  • Acknowledgment – Record Requests & Legal Limitations
    Updated: August 11, 2025

    By submitting this request — whether as a Harmony client or a third-party acting on behalf of one, you agree and understand:

    • Harmony Mental Health does not provide provider recommendations or testimony for legal matters, except Social Security–related claims/appeals (written records only, no testimony).
    • Requests follow the timelines, processes, and fees in our policy HMH Release Policy Disclosure.
    • Third-party requests require valid, signed client authorization before records are released.
    • Mailing via certified mail may include a $10 fee.
    • All records follow HIPAA, state, and federal law.

    📌 Special Note – Social Security Claims
    We do not charge indigent clients for records needed to support a claim or appeal under the Social Security Act (42 USC §301).

  • Client Privacy, Record Release and Consent Agreement

  • Record Request Form

    Harmony Mental Health Inc. [HMH]
  • Requester {Select the one that best applies}*
  • Auth Release Type *

  • REQUEST DETAILS

    Please be sure to complete all required fields marked (*).
  • Record Request Date*
     - -
    • Client Information  
    • DOB*
       - -
    • Requester's Information  
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Request Form  
    • Provider Assigned to Case*

    • STOP HERE — PLEASE CALL OUR OFFICE BEFORE CONTINUING.

      If you marked “Unknown” or “Not Listed” for the provider, this may indicate that the individual you are making the request on behalf of is not, or has not been, a Harmony Mental Health Inc. (HMH) client, or that the provider associated with the request is a former HMH employee. 

      Due to privacy requirements, HMH staff cannot confirm or deny whether an individual is or has been a client of HMH. However, our staff can help determine whether you have sufficient provider information to proceed with your submission.

       

      Contact Information. 

      Monday-Thursday | 8am - 7pm (Lunch from 12pm-1:30pm) 

      Phone #: 304.917.4741

      Email: Rec@harmonymh.org 

    • Treatment Date of Service (DOS)

      Please list the period we can pull and release records: fill in the "From" and the "To" sections below.
    • Authorization Covers From *
       / /
    • Authorization Covers To*
       / /
    • Requested Documentation*
    • Purpose for Request*
    • How would you like to submit authorization for your request.*

    • If you opt to complete the authorization form linked below, you will be required to have it signed and submitted within 24 hours of submitting your record request or your request will automatically be moved to "unfulfilled" due to our inability to verify authorization. You will then be required to submit a new request form. 

      Please use the attached link to complete a Harmony Mental Health, Inc. Authorization to Release and Obtain Form. Password to access form: Harmony1! 

      https://pdf.ac/zGuAN

      Please note that to view and submit the authorization form, you must use the same name and email address you provide on this Record Request Form. 

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    • Delivery Preferences

      Delivery Dates and Preferences cannot be guaranteed. However, we will notify you at least 24 hours before your preferred delivery date if we cannot fulfill your request within the preferred timeframe. Please re-review the "HMH Release policies and fees" section above.
    • Court Date
       - -
    • Preferred Delivery Date*
       - -
    • Preferred Delivery Method*
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Pick-Up (HMH Office Location)*
    • Should be Empty: