Disclosure of Patient Medical Information - MUSC Health 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Name, Date of Birth, and the last four digits of the SSN in the designated fields. This information is crucial for identifying the patient.
3. Fill in the Phone Number and MRN (if applicable) to ensure accurate communication regarding the request.
4. Specify where you want the information sent by filling out the 'To' section, including individual or organization details, attention line, and complete address.
5. Indicate your preferred Release Method/Format by checking one option from Mail, DVD/CD, My Chart, Fax, etc., based on how you wish to receive your records.
6. In the 'Information to be Released' section, check all relevant boxes that apply to your request. Be specific about what records you need.
7. Sign and date at the bottom of the form. Ensure that a witness signature is included if required.

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