Follow the steps to complete your online request for medical records.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by completing the patient information. Write the patient's full name and date of birth in the appropriate fields.
3. For the authorization section, indicate the source of the health information by checking the box next to 'Released From: Urgent Care of Holden.' Then, confirm the destination by checking 'Released To: Urgent Care of Holden' and provide any additional information as required.
4. Fill in the facility or provider information. Complete the street address, city or town, state, and zip code for both 'From' and 'To' sections as prompted.
5. Select the types of information to be used or disclosed by checking all relevant boxes. Options include all medical records, radiology reports, visit encounter provider's chart only, laboratory test results, or other specific information.
6. Indicate if the information includes any confidential details protected under state law by checking the relevant boxes. Options include reportable sexually transmitted diseases and HIV/AIDs results.
7. Choose the dates of service requested. You can select 'All Service Dates on File' or specify particular date(s) if needed.
8. Describe the purpose of the information disclosure by checking all that apply. Possible options include appointments with specialists, legal purposes, continued care, personal use, or other.
9. Carefully read the authorization statements, ensuring you understand the implications of the disclosure. You must then complete the signature section, including the name and date.
10. Once all sections are complete, review the form for any errors. After verifying accuracy, you can save changes, download, print, or share the form as needed.

Start your online request for medical records by completing the form today.