Public Records Request Form - Southern Nevada Health District

Note: Records that include private health information cannot be requested using the Public Records Request form. Visit the Records Request webpage for information on how to obtain medical records.

Fill in all of the information below and click the button to submit your request. An asterisk (*) denotes a required field.


Your Name:*

Address:*
City:*
State:*		Zip:*
Contact Information: * (both are required)
	Phone:
	Email:

Public Records Requested:* Records that include private health information cannot be requested using this form.


Type of Request:

How should the records be sent:


What medium should the records be available? (select all that apply)
	On-site review and inspection (no copy charge)
	Paper copy ($0.60 per medical record page; $1 per page for all other record types)
		Certified paper copy (Additional flat fee of $4)
	Electronic copy (if available)
		CD ($10 each*)	Zip Disk (250M; $11 each*)	Voice Tape ($10 each)	Digital Tape ($40 each*)

Cost does not include research time. The first hour of research time is free. After the first hour, research by clerical staff is $30 per hour and $65 per hour for research done by professional staff.

† Cost does not include programming time. The fee for a programmer to convert and/or format data is $65 per hour. Conversion and formatting is subject to the availability of a health district programmer.

I understand there is a charge for research, programming and copies of public records. Further, I understand that if the estimated cost of the records request is $25 or more, I will be required to pay in full prior to reproduction. Records will be held for 14 days. Payment will be forfeited if the material is not retrieved.

By filling in the fields below, you are giving your digital signature and agreeing to the terms and conditions listed above.

Type Your Name:*	Today's Date:*

Type verification image:*

A printer-friendly receipt will be available once you click the Submit Records Request button.

This form is a public record and will be retained for a period of one year from creation.