Tranquility Behavioral Health Patient Portal

Tranquility Behavioral Health RECORDS/PAPERWORK REQUEST FORM

First & Last Name *

D.O.B. *

PROVIDER *

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

All paperwork request submitted before 4:30pm will be reviewed within 1-2 business days of the day that it is received. Please allow 10-14 business days for your request to be processed after review.

Phone Number *

Email *

Date of MOST RECENT Appointment *

Upcoming Appointment Date *

Please be advised that our office does not provide patients with a personal copy of their medical records regarding Disability, FMLA, CPS cases and legal matters. If you feel that you are in need of a personal copy of your records, please contact the Medical Records Department via phone, and someone will be available to help process your appeal.

Tranquility Behavioral Health Patient Portal

Available Forms

MEDICAL RECORDS/PAPERWORK REQUEST

Tranquility Behavioral Health RECORDS/PAPERWORK REQUEST FORM

Paperwork Fee Schedule

All paperwork request submitted before 4:30pm will be reviewed within 1-2 business days of the day that it is received. Please allow 10-14 business days for your request to be processed after review.

Tranquility Behavioral Health Patient Portal

Available Forms

MEDICAL RECORDS/PAPERWORK REQUEST

Tranquility Behavioral Health RECORDS/PAPERWORK REQUEST FORM

Paperwork Fee Schedule

*All paperwork request submitted before 4:30pm will be reviewed within 1-2 business days of the day that it is received. Please allow 10-14 business days for your request to be processed after review.*

All paperwork request submitted before 4:30pm will be reviewed within 1-2 business days of the day that it is received. Please allow 10-14 business days for your request to be processed after review.