REQUEST FOR RECORDS PHI FROM PREVIOUS PROVIDER 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your personal details. Enter your name, DC MRN #, address, and date of birth in the designated fields. Ensure accuracy for a smooth processing.
3. Next, provide information about your previous physician. Fill in their name, address, suite number, city, zip code, state, phone number, and fax number.
4. In the authorization section, check the specific information you wish to be released. Options include immunization records, imaging records, and more. Select all that apply.
5. Indicate where the records should be sent by filling in the recipient's details. If there are more than 10 pages of records requested, specify that they should be mailed.
6. Finally, sign and date the form at the bottom. If someone other than you is signing, provide their relationship to you and authority.

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