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01. Edit your form online
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Send it via email, link, or fax. You can also download it, export it or print it out.
How to Use or Fill Out the Patient Request for Access to Designated Record Set
- Click ‘Get Form’ to open it in the editor.
- Begin by entering the patient's name, date of birth, and contact phone number in the designated fields.
- If applicable, provide any prior names used by the patient along with their current address, including state, city, and zip code.
- Indicate whether you wish to receive records yourself or disclose them to another recipient by filling out their name and address details.
- Select your preferred method for receiving records: Email, MyChart, Paper, Disc, or Fax.
- Specify the facility or provider from which you are requesting information and include a date range if necessary.
- Check all relevant types of information you wish to disclose such as History & Physical, Operative Report, etc.
- Finally, ensure that you sign and date the form. If a representative is signing on behalf of the patient, include their details and relation.
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