Patient Request to Access/Disclose a Designated Record Set ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the designated fields, including your name, date of birth, prior names used, contact phone number, and address. This ensures that your request is accurately processed.
3. Indicate how you would like to receive your records by selecting one of the options: MyChart, Email, Disc, or Paper. Make sure to provide the recipient's details if you are not receiving them yourself.
4. List the facilities from which you are requesting information. Include both hospitals and clinics as necessary for comprehensive access.
5. Specify the range of dates for the records you wish to access. This helps narrow down the search for relevant documents.
6. Select the types of information you want disclosed by checking the appropriate boxes such as History & Physical, Discharge Summary, etc. If there are additional specifics needed, use the 'Other' field.
7. Finally, sign and date the form at the bottom. If a representative is submitting on your behalf, they must also complete their section.

Start using our platform today for free to streamline your document requests effortlessly!