Request Treatment Records
Obtaining Treatment Records
To request a copy of a client’s treatment records, please fill out and return the Pioneer Human Services (PHS) Authorization to Release Patient Health Information form. You will need to fill out the authorization completely. Failure to complete all required fields may result in a processing delay.
- CLIENT INFORMATION: Print client’s name, date of birth and social security number. Please include the client’s contact phone number and the PHS facility that provided treatment and the client’s contact number if available.
- INFORMATION TO BE RELEASED FROM: Select Pioneer Human Services OR select Other and provide the name of the organization and the specific provider(s). Include the address, phone and fax number.
- INFORMATION TO BE RELEASED TO: Select Pioneer Human Services OR select Other and provide the name of the organization and the specific provider(s). Include the address, phone and fax number.
- PURPOSE OF RELEASE: Select the reason records are being requested. Initial where indicated.
- TYPE OF INFORMATION REQUESTED: Specify what type of information to be released. Initial where indicated.
- DESCRIPTION OF THE INFORMATION TO BE USED/DISCLOSED: Describe the type of information that is to be disclosed. Initial where indicated.
- MY RIGHTS / MY AUTHORIZATION: Please read your rights and indicate when the authorization to disclose would expire. We suggest one month to expiration or 30 days.
- SIGNATURE: Sign and date as indicated. If not signed by the client, documentation may be required to prove authority to sign on behalf of the client.