Requests for records that include medical information require an Authorization to Use and Disclose PHI Form. You may attach a completed form to your request or choose to have the form sent to you after your request has been reviewed. If proof of identification is required, we will contact you with instructions for submitting it.

First Name of Requestor (required)

Last Name of Requestor (required)

Mailing Address (required)

Phone Number (required)

Email Address (required)

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Public Records Request Details

Description of Records Requested (required)

Date(s) Incident Occurred (required)

Incident Address (required)

Are you requesting medical records? (required)

Yes

No

I understand that additional information or documentation, including proof of identity if applicable, may be required to process my records request. (required)

Yes

No

If the identified records include medical records of a District patient, a Authorization to Use and Disclose PHI Form will be required. (required)

Yes, the Authorization to Use and Disclose PHI Form is attached to this request.

Yes, please send me the required form to complete once you have reviewed my request.

This does not apply to my request.

Attach Completed Authorization to Use and Disclose PHI Form

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I understand that by signing this form with my electronic signatures my signature is the legal equivalent of my manual/handwritten signature. I herewith affirm that my electronic signature was signed by myself with my  full knowledge and consent.

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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