Request for Records/Letters

Record/Letter Request Form

If you are requesting any records or letters from Mesa Vista Wellness, please submit a Release of Information Form along with this form specifying your request. Please be advised that Mesa Vista Wellness has up to 30 days to complete record requests.

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Request for Letters/Records *

Request for Letter

Request for Records

Client First Name: *

Client Last Name: *

Client Date of Birth: *

I hereby authorize Mesa Vista Wellness to release the following (please be specific) : *

Please choose how you would like the recipient to receive the letter/records and provide the recipient's information: *

FaxFax

MailMail

EmailEmail

OtherOther

Signature of Client *

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Signature of Legal Guardian for Minors

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Request for Records/Letters

Record/Letter Request Form

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Request for Records/Letters

Record/Letter Request Form

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