Record Release Form ( PDF ) - Oak Orchard Community Health Center - oakorchardhealth 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your name and the name of the doctor at Oak Orchard Community Health Center who will be releasing your records. Ensure you provide a complete address for accurate processing.
3. Select the appropriate option for how you want your records handled: sending, obtaining, picking up, or sharing verbally. Fill in any necessary contact details such as phone number and fax number.
4. Indicate whether you are transferring care by checking the relevant box. If transferring, complete the survey on the reverse side as instructed.
5. Specify the purpose of your request clearly in the designated section to ensure proper handling of your information.
6. Complete the section regarding which records you wish to receive, either all records or selected information. Be specific about what you need.
7. Fill out patient details including name, date of birth, relationship to signer, and chart number for each individual if applicable.
8. Sign and date the form at the bottom. Make sure to include your address and have a witness sign if required.

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