Follow the steps to complete your request effectively.

1. Press the ‘Get Form’ button to obtain the Patient Request for Access to Designated Record Set - Kadlec form and open it in your editor.
2. Fill in the patient’s name, date of birth (DOB), contact phone number, prior names used, address, state, city, and zip code. Ensure to enter the patient’s email address accurately.
3. Indicate whether you wish to disclose your records to yourself at the address provided or specify a different recipient. If a different recipient is selected, fill in their name, address, city, state, zip code, as well as their fax number and phone number.
4. Specify the method for receiving the records by selecting from the options: Email, MyChart, Paper, Disc, or Fax.
5. List the facility or provider names from which you are requesting information. You may specify hospital(s) or clinic(s) as needed.
6. Indicate the date range of records you are requesting, if applicable.
7. Select the type of information you wish to disclose by checking the relevant boxes including history & physical, operative report, diagnostic report, discharge summary, emergency department report, progress notes, or last 2 years only.
8. Review your completed form carefully to ensure all information is correct.
9. Sign and date the form, as well as include the representative name and signature if applicable. Make sure to provide any necessary supporting documentation.
10. Once all fields are completed and checked, save any changes, and proceed to download, print, or share the completed form.

Start completing your request for access to your medical records online today!