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How to use or fill out REQUEST FOR RECORDS PHI FROM PREVIOUS PROVIDER with our platform
- Click ‘Get Form’ to open it in the editor.
- 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.
- Next, provide information about your previous physician. Fill in their name, address, suite number, city, zip code, state, phone number, and fax number.
- 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.
- 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.
- 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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