775-204-0150 (Call or Text) hello@nvpfm.com
  • Book Meet & Greet
  • Forms
  • Blog
  • Healthshare
  • COVID-19
    • COVID-19 Testing
  • Opportunities
Preferred Family Medicine
  • Home
  • About
    • Our Mission & Team
    • Testimonials / Reviews
  • Services
    • Services List
    • Comprehensive Wellness Program
    • Corporate Plans
      • Employers
      • Corporate Membership Sign-Up
      • Corporate COVID-19 Testing Program
    • CDL / DOT Physicals
    • Flight Physicals
    • Vision & Eye Care
    • Medical Weight Loss Program
    • Dermatology Services
    • School Sports Physical
    • Vasectomy
    • Circumcision
    • COVID-19 Testing
  • Pricing
  • FAQ
  • Contact
  • Members
    • Member Page
    • Patient Portal
Select Page

Request Medical Records

Authorization to Obtain Personal Health Information (From Another Provider)

  • Enter your mailing address
    Records to be sent to: Preferred Family Medicine, 10627 Professional Circle, Suite A, Reno, NV 89521 PHONE: (775)-204-0150 FAX: 775-501-6360
  • e.g. "Dr John Doe", "General Hospital", or "ABC Assisted Living", etc.
  • If you know it, please provide the health care provider's phone number.
  • If you know it, please provider the Health care provider's fax number. If not, we will obtain it.
  • Obtain records FROM this date.
  • Obtain records TO this date.
    (Select all that apply)
  • Regarding Mental Health: 1) Copies of medical records pertaining to diagnosis and/or treatment of psychiatric, psychological conditions and/or drug or alcohol abuse may be released to the recipient as noted above. 2) Copies of medical records, including information of the diagnosis and/or treatment for AIDS/HIV (including testing) may be released to the recipient as noted above.
  • I understand that if the person(s) and/or organization(s) listed above are not health care providers, health plans, or health care clearinghouses, who must follow the federal privacy standards, the health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards and my health information may be redisclosed without obtaining my authorization.
  • Your Rights with Respect to This Authorization: · Right to Receive Copy of This Authorization- I understand that if I agree to sign this authorization, which I am not required to do, I must be provided with a signed copy of the form. · Right to Refuse to Sign This Authorization- I understand that I am under no obligation to sign this form and that the person(s) and/or organization(s) listed above who I am authorizing to use and/or disclose my information may not condition treatment or payment, on my decision to sign this authorization. · Right to Withdraw This Authorization- I understand written notification is necessary to cancel this authorization. To obtain information on how to withdraw my authorization or to receive a copy of my withdrawal, I may contact the Director of Health Information Management at (775) 204-0150. I am aware that the revocation will not apply to information that has already been released in response to this authorization.
  • If I fail to specify an expiration date or event, this authorization will expire 90 days from the date on which it was signed. I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • Opportunities
  • Testimonials
  • Business Owners
  • Pharma / Vendors
  • Privacy
  • Blog
  • Contact
  • Become a PFM Physician Affiliate
  • Log out
  • Facebook
  • Twitter
  • Instagram
  • RSS
All rights reserved | Preferred Family Medicine | Copyright 2023 | This practice does not constitute insurance. This practice provides only the limited scope of primary care as specified in the retainer medical agreement. Specialty and/or hospital care, pharmaceuticals, and testing (labs that are not included, X-ray, Ultrasound, etc.) are not covered by your fee and are your financial responsibility.