Southern Nevada Family & Occupational Health

Available Forms

Client Invoice(s) Immigration Secure Deposit Medical Records Invoice

Medical Records Invoice

Credit Card Information & Authorization Form

**This form is ONLY to pay for Medical Records . If you are trying to pay a balance regarding a primary care bill please call 702-733-6622 ext 206**

Patient's Name *

Full Name

Date of Birth *

Type of Card *

Visa

Mastercard

*Only VISA or MASTERCARD*

Company Name *

Company Requesting Records

Name on the Card *

Card Number *

Expiration Date *

Month/Year

Security Code *

CVV

Zip Code *

Billing

Amount *

Today's Date *

I certify that I am an authorized user of the credit card referenced above. I authorize SNOHC to charge the credit card listed on this authorization form to process the invoice for the medical records requested.

Authorized by *

First & Last Name

* Incorrect payment information will delay process of payment and release of medical records. If records are not received within 1-2 business days, please reach out to our Medical Records Department at 702-380-1712 ext 313.

* Required field