Boice-Willis Clinic, PA Fax: 252-937-2903-2026

1. Click ‘Get Form’ to open the document in the editor.
2. Begin by entering your Patient Name, Date of Birth, Address, Phone Number, City, State, and Zip Code in the designated fields.
3. Indicate whether you are requesting information to be disclosed 'To' or 'From' by checking the appropriate box and filling in the relevant details for the facility or person.
4. Specify the purpose for which your health information will be used by selecting from the options provided.
5. Choose how you would like your medical records to be sent: via mail, fax (provide fax number), or email (provide email address).
6. Select which specific records you wish to disclose by checking the corresponding boxes.
7. Sign and date the form at the bottom as either the patient or personal representative. Ensure all required fields are completed before submission.

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