Tranquility Behavioral Health Patient Portal

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.

This form is used to request copies or transmission of medical records maintained by Tranquility Behavioral Health LLC & TMS Center. Submission of this form does not guarantee approval and is subject to review in accordance with HIPAA and applicable state and federal regulations.

First & Last Name * D.O.B. * Date of Request * Is this request related to a BILLING Issue? * Which of the following are you requesting? * Purpose of Disclosure * Explain Other Here: Have you completed a Release of Information (ROI) Authorization Form for this request? * Delivery Method (select one) *

Fees & Payment Acknowledgment

I understand that medical records requests may be subject to the following fees: ? $25.00 Digital Record Management Fee (flash drive delivery, if applicable) ? $15.00 ? $25.00 Notarization Fee (if requested) Payment is required prior to release of records.

Have you submitted payment? * If yes, enter date here *

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

Type of Pet, Name of Pet Age, & Breed

Important Medical Records Notice Please be advised that Tranquility Behavioral Health LLC & TMS Center does not provide patients with personal copies of medical records related to Disability, FMLA, CPS cases, or legal matters. If you are requesting records for one of these purposes, your request will be reviewed and may require submission of a separate Medical Records ROI Authorization or an appeal through the Medical Records Department.

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.

HIPAA Acknowledgment

By submitting this request, I acknowledge that: ? This request is subject to review and approval ? Records released will be limited to the scope approved ? Processing timelines apply ? This request does not override federal or state privacy regulations

Processing Timeline

All medical records requests submitted before 4:30 PM will be reviewed within 1?2 business days. Please allow 10?14 business days for processing after review and payment confirmation.

Patient Acknowledgement *

Tranquility Behavioral Health LLC & TMS Center Life is like a butterfly ? beautiful, ever-changing, and transformative. Affordable Answers. Compassionate Care. Neurocognitive Testing You Can Trust.