Disclose Information to: Mark box if patient is completing the form and wanting records sent to themselves. If the records are to go to someone other than the patient, fill in who/where the records are to be sent to along with the address. Can be a person or another healthcare facility
Disclosure by: Identify which facility you want records from (can mark more than one)
Information Disclosed: Identify specific records you are requesting. Be sure to note the dates of service needed/approximate dates of service are fine.