CHS HIM WEB FORM

2. Requestor Information*

4. Last Name*

5. First Name*

7. Phone*

8. Email Address*

10. Requestor Options
    -- Select One --Adoption AgencyAdult Probation ASH - AZ State HospAZ DES AZ DOCCare CenterCoconino CountyCourt Appointed AttorneyCrisis NetworkDesert Vista Dr. OfficeExperts (behavioral health)Legal Advocate M.C. CIVIL DIVISIONM.C. Risk Management MCSOMedical ExaminerMitigation SpecialistOut of StatePatient/Self Pinal CountyPrivate Attorney Public Defender RelativeSalvation ArmySocial ServicesYavapai CountyOTHER (specify)

    Select the requestor option that best defines you.

12. Other

14. Patient Information*

16. Last Name*

17. First Name*

19. Date of Birth*

20. Booking Number

22. Upload Signed Authorization for Release

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23. Upload copy of State Issued Identification, Business or Facility Letter

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25. 1. Receive an email copy of this form.
26. Email address

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27. Submit

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