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Medical Release Form

To request medical records please click here to download and print the medical release form.

Return the form by doing one of the following:


Releasing of medical records costs:

  • Personal Request-Printed: $25.00 + .30 per page + Certified Mail Postage if applicable 

  • Personal Request-Electronic: $6.50 flat fee

Printed records can be picked up in person (with identification) by appointment at 
Piller Child Development Administration Office
2150 S. Country Club Rd 
Suite 10 
Mesa AZ 85210 
or mailed USPS certified mail.

Payment is required before release

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