1. Person (s)/Facility Authorized to receive.
if the copies are for personal reasons and you are picking them up-state “self”. If the records are being picked up by another person or mailed, please provide the complete name and address of the person/agency/etc., you would like us to give/send the copies to.
2. Records Delivery: How you would like your records to delivered. Fax option is reserved for physicians/hospitals/insurance only. We cannot fax directly to you.
3. Dates of Service: Please be as specific as possible with the admit/discharge dates. The approximate month and correct year will be acceptable.
4. Type of documents requested: Please mark all boxes that apply.
5. Purpose of request: Why do you want this information copied or sent? ( ie., personal copy, continuation of care by a physician, insurance claim, legal issues, etc. )
6. Signature Line: Sign and date the form. All signatures will be verified. (Witness signature should be left blank)