Form 4254-2026

1. Click ‘Get Form’ to open the form 4254 in the editor.
2. Begin by entering the date in the format YYYYMMDD. This is essential for tracking your request.
3. Fill in the patient's name and Social Security Number (SSN) accurately to ensure proper identification.
4. Specify the Medical Treatment Facility's name and location where care was provided, as this information is crucial for processing your request.
5. Clearly state the reason for your request in the designated field to provide context for the medical information sought.
6. In the section for Private Medical Information Sought, specify any relevant dates of hospitalization or clinic visits along with diagnoses if known.
7. Complete your details by entering your name, title, organization, and SSN in the requestor's section.
8. If you are part of a Medical Treatment Facility, check the applicable box indicating whether the request is approved or disapproved and provide a reason if disapproved.
9. Finally, ensure that an approving official signs and dates the form to validate it before submission.

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