Tranquility Behavioral Health Patient Portal

2026 PAPERWORK REQUEST FORM

OUR CORE PILLARS OF CARE --Medication Management ? Precision & Partnership --Neurocognitive Testing + Tranquility EDU ? --Clarity Through Understanding --TMS Therapy ? The Science of Renewal --Tranquility360 Mind + Life ? The Art of Letting Life Unfold --These pillars guide how we listen, respond, and care for every patient ? with compassion, clarity, and calm.

First & Last Name *

D.O.B. *

Date of Request *

Is this request related to a BILLING Issue? *

If your answer to this question is yes, please be sure to describe the your concerns in the Chief Complaint. BILLING issues include Patient Unpaid Balances, Superbills, and No-Show Fees.

Which of the following are you requesting? *

Purpose of Disclosure *

Please describe any important details/background information you feel we should know regarding your paperwork request such as, deadlines, a designated point of contact, phone numbers, etc. If you are in need of medication refills, please fill out designated Refill Request Form.

Have you completed a Release of Information Form? *

Yes

Note that this form must be completed before in PHI can be forwarded to the intended recipient.

Have you paid the appropriate fee associated with your particular paperwork request? *

Yes

If answered yes, please input the payment date.

Payment Date

Paperwork Fee Schedule

Select one

If applying for a Service Animal Authorization Letter, Please provide the following details:

Type of Pet, Name of Pet Age, & Breed

Please describe the paperwork you are requesting and how it will be used. This helps us serve you with intention and efficiency. Thank you for being part of the Tranquility community.

Phone Number *

Email *

Date of MOST RECENT Appointment *

Upcoming Appointment Date *

Please be advised that our office does not provide patients with personal copies of medical records for Disability, FMLA, CPS, or legal matters. If you believe you need a personal copy of your records, please contact our Medical Records Department by phone, and a team member will assist you with the appeal process.

THE TRANQUILITY WAY PROMISE ?Every message is a moment of transformation. We listen with calm, respond with clarity, and honor each person?s journey? because healing, like a butterfly, unfolds in its own time.?

Tranquility Behavioral Health Patient Portal

Available Forms

2026 PAPERWORK REQUEST

2026 PAPERWORK REQUEST FORM

Paperwork Fee Schedule

Please describe the paperwork you are requesting and how it will be used. This helps us serve you with intention and efficiency. Thank you for being part of the Tranquility community.