Get Da Form 4254

The Da Form 4254 is crucial for requesting private medical information. Completing this form accurately online ensures that you can obtain necessary information efficiently.

Follow the steps to complete your Da Form 4254 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date in the first field to indicate when the request is being made.
3. Provide the patient's name and social security number in the designated fields to identify the individual whose medical information is being requested.
4. Fill out the medical treatment facility’s name and location to specify where the patient's treatment occurred.
5. State the reason for the request clearly in the corresponding field to justify the inquiry.
6. Specify the private medical information sought, including any relevant dates of hospitalization or clinic visits, as well as the diagnosis if known.
7. Provide the requestor's name, title, organization, and social security number to identify who is making the request.
8. If you are a medical treatment facility official, check the applicable box to approve or disapprove the request. If disapproved, state the reason for disapproval in the space provided.
9. Summarize the private medical information that will be released in the designated area to provide transparency on what is being shared.
10. Ensure the signature of the approving official is included to validate the request.
11. Finally, enter the date of approval to document when the request was processed.
12. Once all sections are complete, save any changes, download the form, print it for your records, or share it as needed.

Complete your Da Form 4254 online to streamline your request for private medical information.