Valleyhealthsystemlv sitesvalleyhealthSummerlin Hospital Authorization to Use and Disclose 2026

1. Click ‘Get Form’ to open the valleyhealthsystemlv sitesvalleyhealthSummerlin Hospital Authorization to Use and Disclose in the editor.
2. Initial the first box if you are requesting records from Summerlin Hospital. If you want records sent from another facility, initial the second box. For viewing original medical records, initial the third box.
3. Fill in your Patient Name at Time of Treatment, Date of Birth, and Social Security Number. Provide your contact information including home and work phone numbers and street address.
4. In the middle section, indicate who is authorized to receive the PHI by checking the appropriate box. Specify the purpose of disclosure such as continued care or personal use.
5. Describe the specific records needed by providing treatment dates and checking relevant documentation types. Initial next to any highly confidential information you wish to disclose.
6. Sign and date the form to validate it. If applicable, have a legal representative sign and indicate their relationship to you.
7. Finally, choose how you would like to receive your PHI: by mail, pickup, or fax.

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