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:
in person at 10631 S. 51st Street, Suite 1, Phoenix AZ 85044
Fax to 844-526-2649
email completed form to firstname.lastname@example.org
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
Mesa AZ 85210
or mailed USPS certified mail.
Payment is required before release