Download form (PDF) - Summerlin Hospital Medical Center 2026

1. Click ‘Get Form’ to open it in the editor.
2. Initial the first box if you are requesting records from Summerlin Hospital Medical Center. If you need records from another facility, initial the second box.
3. Fill in your Patient Name at Time of Treatment, Date of Birth, and Social Security Number.
4. Provide your Street Address, City, State, Home Phone Number, Work Phone Number, and Zip Code.
5. In the middle section, indicate the Person(s)/Organization authorized to release and receive the PHI by checking the appropriate boxes.
6. Specify the Purpose of Requested Use or Disclosure and describe the information included in Use or Disclosure by checking relevant boxes.
7. Initial next to any highly confidential information you wish to disclose and list an expiration date for this authorization.
8. Sign and date the Authorization. If applicable, have a Legal Representative sign as well.

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