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Client Records Request Form

Crisis Preparation and Recovery Inc.
Phone 480.804.0326
Fax 480.804.0083
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
I hereby request a copy of the following Crisis Preparation & Recovery, Inc. (CPR) records:
* 
CPR Assessments/Psychiatric Evaluations  Treatment/Service Plans  Progress/Service Notes 
Labs  Medical Services  OQ Measures 
Other:  
Please provide this information to me in the following way:
* 
I will pick up my records at the following CPR Office and provide identification at this time.   Mail my records to the following address (if blank, use the address listed above)   Send an encrypted email to the following email address:  
Please FAX to third party at this FAX Number (Type the name of who the Fax is going to)     
FAX Number
I understand that I MUST provide identification in order to get a copy of my records. If the Records Department is unable to get a copy of my identification, I will be asked to have my signature notarized. I understand that I can change the format in which I receive my records at any time. I understand that the first copy of my records is free, and any additional copies for the will be charged at $0.25 per page with a clerical fee of $10.00 per hour and related postage. Pursuant to 45 CFR § 164.524 Crisis Preparation and Recovery, Inc. will act upon all client requests for records as soon as possible, but no later than 30 calendar days of receipt of the request. A copy of this authorization is available to me upon my request.
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