Note: There will be a charge of $6 2026

1. Click ‘Get Form’ to open it in the editor.
2. Initial the first box if you are requesting records from Summerlin Hospital. This includes any request to disclose records to another health care provider.
3. Fill in your personal information, including Patient Name, Date of Birth, and Social Security Number.
4. Indicate the Person(s)/Organization authorized to release the records by checking the appropriate box.
5. Specify the purpose of the disclosure by selecting from options like continued patient care or personal use.
6. Provide a description of the specific records you wish to obtain by checking relevant boxes and entering treatment dates.
7. Initial next to any highly confidential information categories that apply to authorize their disclosure.
8. Sign and date the Authorization at the bottom of the form to validate it. Ensure all required fields are completed before submission.

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