top of page

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 office.staff@pillerchilddevelopment.com
Releasing of medical records costs:
-
First 10 pages are free/ calendar year
-
Records over 10 pages costs $15.00 + .25/ page over 10 pages
-
Records can be picked up in person (with identification) or mailed *certified mail.
-
*Records mailed will be charged certified mail postage in addition to any processing fees.
bottom of page