ADHS Records Request

Confidentiality Disclaimers*

ADHS is required by The Health Insurance Portability and Accountability Act (HIPAA) to protect the identities of patients and family members in our records. ADHS is required to redact various portions of complaints and surveys according to HIPAA and records you seek may have redactions when returned.

ADHS is required pursuant to Arizona Revised Statute 36-2810 regarding the Medical Marijuana Act to keep records confidential with respect to applications or renewals, including information submitted by qualifying patients and designated caregivers, physical addresses of nonprofit medical marijuana dispensaries, and individual names or other identifying information who has an issued registry identification card.

*Please note that ADHS is required to follow various state and federal laws regarding confidentiality. The above referenced confidentiality disclaimers are common examples, however, are not all-encompassing.

If you are requesting public records for commercial purposes, a fee will apply.

Medical Records Specifications

Please indicate that you understand that ADHS is not a medical provider, is not the custodian of personal medical records, and does not maintain a medical records warehouse.

Yes, I understand. *

Are you seeking any of the following specific medical records? *

(Please note this does not include Immunization, Birth, or Death records. See below for records request information.)

Newborn Screening records

Arizona State Hospital patient records

Office of Infectious Diseases records (e.g. HIV, Hepatitis C)

None of the above

For a medical record, an Authorization/Release of Information Form is required. Please submit your completed form here*

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Note:

ADHS requires a notarized authorization addressed to ADHS and executed by the patient or patient’s representative, as well as the representative’s relationship to the patient stated on the authorization form.
If the authorization is not notarized, please submit a copy of the patient or representative’s government-issued identification, which,

includes their signature, and
a copy of a legal document that verifies their legal authority to sign on behalf of the patient (e.g. birth certificate, power of attorney, proof of legal guardianship, etc.).

ADHS cannot confirm the existence of records without the above information.

For Immunization information and records, please visit our ADHS Immunization Program website or submit a request here: Immunization Record Request.

For Vital Records information, please visit our ADHS Vital Records website, where you can request Birth and Death Certificates.

Requestor Information

First Name *

First Name Required.

Last Name *

Last Name Required.

Phone Number *

Phone Number Required.

Email Address *

Email Address Required.

Confirm Email Address *

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Preferred method of contact? *

Preferred method of contact Required.

I/we are affiliated with: *

Affiliation Required.

Name of government agency, organization, or law office you are affiliated with (if applicable)

Acknowledgments & Survey

I understand by submitting this request, the information I have included becomes a public record. *

Yes, I understand.

Confirmation Required.

I understand that ADHS records retention timelines will vary, The Health Insurance Portability and Accountability Act (HIPAA), and Arizona Revised Statutes can result in redaction of information in the records returned. *

Yes, I understand.

Confirmation Required.

ADHS has recently revised this form. We would like your feedback on how clear this form is in describing your records request. *

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Somewhat unclear

Neutral

Somewhat clear

Very clear

How are we doing? Please provide any additional feedback on this form and portal.

Record requests are processed as efficiently as possible, but timelines may vary depending on the nature of the request. We work diligently to meet each request in a timely manner and appreciate your understanding of any delays that may arise due to the volume or complexity of the records. If you'd like to check the status of your request, please login to your account or enter your reference number here anytime after form submission.

Record Request Form

Medical Records Specifications

Requestor Information

Records Request Specific Information

Acknowledgments & Survey

Thank you for submitting your request!

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