Request for Health Records

Patient Health Records

Correctional Health Services (CHS) Health Information Management (HIM) maintains formerly and currently incarcerated patients' health records electronically.
See below for instructions on how to request health records.

Required Documents

The following items are required:

  1. Completed Authorization for Release of Health Information form (filled out, signed, and dated by the patient)
  2. A copy of state-issued identification of the requestor


Authorization for Release of Health Information Form

Remember when filling out the Authorization for Release of Health Information form, the following are required:

  • All sections must be completed
  • The patient must fill out, sign, and date the Authorization
  • The Authorization will need to be returned to the Health Information Management staff for processing
  •  A copy of the state-issued identification of the requestor must be included along with the Authorization


Note that only completed documents will be processed.

You can download the Authorization for Release of Health Information form by clicking the link below. Please remember ALL sections of the form must be completed.

Download Authorization for Release of Health Information Form

  1. Authorization For Release Of Health Information (English)
  2. Authorization For Release Of Health Information (Spanish)

Submitting Authorization

There are three ways to submit your completed Authorization:

  1. You may electronically send the Authorization along with a copy of state-issued identification of the requestor to the following email address: CHSHIMROI@Maricopa.gov
  2. You may fax your completed Authorization request along with a copy of the state-issued identification of the requestor to the following fax number: 602-372-6764
  3. You may mail your completed Authorization along with a copy of state-issued identification of the requestor to:

Maricopa County Correctional Health Services
Attn: Health Information Management
234 N. Central Ave, STE 5400, Phoenix, AZ 85004

NOTE:
After submitting your completed Authorization form, you will be notified electronically by automatic response that your request has been received. You will typically be contacted within 7-10 business days. 

Payment instructions will be included within the fee letter you receive once your request has been approved. Please DO NOT submit payment until notified to do so.

Records will be processed within 30 days of receipt. If a fee is required, records will be processed within 30 days of receipt of payment notification.

Fees

Ensure your cashier’s check, money order, or business check is made payable to MARICOPA COUNTY CORRECTIONAL HEALTH SERVICES. Note that NO PERSONAL CHECKS WILL BE ACCEPTED.

  • Electronic records are a flat fee of $6.50 for standard requests for records that are maintained and fulfilled electronically
  • Paper copies are $10.00 for the first 10 pages and $.50 for each additional page
  • Fees take 7-10 days to process


Hours of operation: 

Monday through Friday, 8:00 am to 4:00 pm
Closed weekends and holidays

CHS Health Records Contact Number: 602-506-3509