To request records from Chandler Regional Medical Center, you complete the Dignity Health Authorization for Use or Disclosure of Protected Health Information form and send it to the hospital’s Health Information Management (HIM) department. The Chandler Regional Medical Center medical records release form is a downloadable PDF on the Dignity Health Arizona medical records page, and the same form covers Mercy Gilbert Medical Center if you have been seen there too.1Dignity Health. Patient Medical Records – Arizona Hospitals
Getting the Form
Download the PDF from Dignity Health’s Arizona medical records page, or pick up a paper copy from the HIM office at 1955 W. Frye Rd., Chandler, AZ 85224, Monday through Friday, 8 a.m. to 4:30 p.m.2Dignity Health. Dignity Health Arizona Medical Records
Before you sit down with the form, pull together a government-issued photo ID (an Arizona driver’s license or U.S. passport works), the approximate dates of the treatment you want records for, and any legal documents you will need if you are signing on someone else’s behalf.
Filling Out Each Section
A valid HIPAA authorization has to include several specific pieces of information, and the Chandler Regional form has a field for each.3eCFR. 45 CFR 164.508 – Uses and Disclosures for Which an Authorization Is Required Work through it top to bottom and leave nothing blank. Incomplete forms get bounced back, and that resets your timeline.
Patient identification. Enter the patient’s full legal name, date of birth, and Social Security number. HIM uses these to pull the correct chart.
Description of information. Specify what you want. Common categories are discharge summaries, operative reports, laboratory results, diagnostic imaging, and physician progress notes. Check only what you actually need. A narrower request processes faster and costs less to copy.
Dates of service. Give a date range that matches the care you are asking about. “All records from 2018 to present” is fine when you need a continuous history, but a tighter window keeps copying charges down.
Recipient information. Name the person or organization that should receive the records, with a mailing address. That may be you, another provider, an attorney, or an insurer.
Purpose of disclosure. Say why the records are being released. “At the request of the individual” is enough when you are asking for your own records. Other common purposes are continued medical care, insurance claims, and legal proceedings.3eCFR. 45 CFR 164.508 – Uses and Disclosures for Which an Authorization Is Required
Expiration. Every authorization needs an endpoint, either a calendar date or a triggering event like “upon completion of my disability claim.” Without one, the form is not valid.
Signature and date. Sign and date at the bottom. If a legal representative is signing for the patient, the form has to describe that person’s authority (for example, “healthcare power of attorney” or “legal guardian”), and a copy of the supporting document should be attached.4U.S. Department of Health and Human Services. Can a Health Care Power of Attorney Obtain Access to the Individual’s Medical Record
Psychotherapy Notes Need a Separate Authorization
The private session-by-session notes a therapist keeps apart from your main chart are treated separately under HIPAA. A general “release all my records” request does not reach them, and the hospital cannot release them under that language. If you need those notes, ask HIM for the dedicated authorization.
Submitting the Form
Chandler Regional accepts completed forms three ways. Include a legible copy of your photo ID with whichever method you use.2Dignity Health. Dignity Health Arizona Medical Records
- Mail or in-person delivery to Health Information Management Department, 1955 W. Frye Rd., Chandler, AZ 85224. If you mail it, use a tracked service so you have proof of delivery.
- Fax to (480) 728-3980. Keep the confirmation page as your receipt.
- Email a scanned PDF to dignityhealth-az-roi@commonspirit.org. This inbox handles releases for all Dignity Health Arizona facilities.
A blurry ID scan or one that crops off part of the card will prompt a follow-up and stall your request. For questions about a request you already sent, call HIM at (480) 728-3125.
How Long It Takes
Federal law gives a hospital 30 calendar days to act on your request, meaning either release the records or send a written denial.5U.S. Department of Health and Human Services. How Timely Must a Covered Entity Be in Responding to Individuals The hospital may take one additional 30-day extension, but only by notifying you in writing during the first 30 days with the reason and a specific completion date.6eCFR. 45 CFR 164.524 – Access of Individuals to Protected Health Information Arizona’s statute uses a “promptly available” standard without a set number of days, so the 30-day federal clock is the deadline that matters in practice.7Arizona Medical Board. Medical Records – Physician Obligations If the deadline passes with no records and no denial, you can file a complaint with the HHS Office for Civil Rights.
What It Costs
Arizona law allows a “reasonable fee” for reproducing records but does not set a per-page rate.8Arizona Legislature. Arizona Revised Statutes Title 12 – Section 12-2295 Under HIPAA, the charge can only cover the actual labor for copying, supplies, and postage if you ask for the records mailed. Search-and-retrieval charges for locating your file are not allowed.9eCFR. 45 CFR 164.524 – Access of Individuals to Protected Health Information For electronic copies, HHS treats up to $6.50 as a safe-harbor flat fee that meets the reasonable-cost standard.
Arizona law bars the hospital from charging you at all in three situations:8Arizona Legislature. Arizona Revised Statutes Title 12 – Section 12-2295
- Records sent to another provider for continuing care.
- Records you request for the demonstrated purpose of getting health care for yourself.
- Records requested by you or your representative to appeal a denial of Social Security benefits. A representative has to provide a completed SSA-1696.
Expect an invoice before the records go out if a fee applies. If the total looks high, ask HIM to itemize. Hospitals sometimes apply an attorney-request fee schedule to a patient request by mistake.
Signing on Someone Else’s Behalf
For a Minor Child
A parent or legal guardian is generally the child’s personal representative and can sign the authorization for the child.10HealthIT.gov. Your Health Information Rights Under Arizona law, a parent who is the child’s health care decision maker can request the minor’s records with a written request.11Arizona Legislature. Arizona Code 12-2293 – Release of Medical Records and Payment Records to Patients and Health Care Decision Makers
Two narrow limits apply. The hospital may deny parental access when a licensed professional determines that release is reasonably likely to cause substantial harm to the child or another person. And Arizona protects the confidentiality of certain minor-consented care: treatment for sexually transmitted diseases at any age, and substance abuse treatment for minors 12 and older. Records from those visits are not automatically available to a parent.
For a Deceased Patient
HIPAA protections continue for 50 years after death. The executor or administrator of the estate, or another person with legal authority to act for the estate, uses the same authorization form and attaches:
- A certified copy of the death certificate.
- Court documentation of legal authority, such as letters testamentary or letters of administration.
- A government-issued photo ID for the requester.
A spouse or adult child without legal authority over the estate does not automatically get the full record. If that is your situation, ask HIM what limited information may still be available.
Canceling an Authorization
You can revoke an authorization at any time with a written notice to HIM. The revocation applies going forward only. Records already released while the authorization was active cannot be pulled back. If you switched attorneys, for example, revoke the old authorization right away and sign a fresh one naming the new firm.
If the Hospital Denies the Request
The hospital can deny access only on specific HIPAA grounds.6eCFR. 45 CFR 164.524 – Access of Individuals to Protected Health Information Some denials, such as those for psychotherapy notes or information compiled in anticipation of a lawsuit, are not reviewable. Others are reviewable, which means you can ask in writing for a different licensed professional to re-evaluate the decision. Reviewable denials come up when a clinician has decided that access is reasonably likely to endanger your life or physical safety, cause substantial harm to another person named in the records, or cause harm through a personal representative.