Diagnosis Request

At Alternative Wellness Services (AWS), we prioritize the confidentiality and release of personal health information, implementing strict procedures to ensure compliance and timely access. Managing medical record requests is a critical aspect of our operations, stemming from various sources, including clients, guardians, state agencies, external providers, disability determination services, and legal professionals.

Our Records Request Policy

Provider Requesting Diagnosis(Required)

Request Date(Required)

Client First Name(Required)

Client Last Name(Required)

Client D.O.B.(Required)

Diagnosis Information

Primary Behavioral Health Diagnosis

Name/Description(Required)

ICD-10

DSM-5

Diagnostic Code(Required)

Additional Diagnosis

Name/Description

Name/Description of Additional Diagnosis

ICD-10

DSM-5

Diagnostic Code

Additional Diagnosis

Name/Description

Name/Description of Additional Diagnosis

ICD-10

DSM-5

Diagnostic Code

Information About Provider Providing Documenting Diagnosis

Provider name with credentials:(Required)

Email(Required)

Enter Email Confirm Email

Diagnosis Request

Diagnosis Information

Primary Behavioral Health Diagnosis

Additional Diagnosis

Additional Diagnosis

Information About Provider Providing Documenting Diagnosis

Administration Office:

Clinical Office:

Clinical Office:

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Second Insurance Provider

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Third Insurance Provider