COMPLETED IN FULL OR 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by checking one of the boxes at the top of the form to indicate whether you are requesting medical records copies or forms processing. Note the associated fees.
3. Fill in your personal information, including your name, phone number, date of birth, and address. Ensure all fields are completed accurately.
4. Specify the date(s) of service needed by entering the 'From' and 'To' dates.
5. Indicate which provider at the Center for Sports Medicine you are requesting records from by writing their name in the designated field.
6. Describe the information you are requesting, such as office notes or lab reports, in the provided section.
7. Enter your personal email address for electronic delivery of documents. This is a required field.
8. If applicable, fill out the section for releasing records to another person or entity, including their name and contact details.
9. Sign and date the form at the bottom to authorize the release of your protected health information.

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