* Full Name:

* Organization:

* Phone Number:

* Email Address:

* Date:

Please describe, in as much detail as possible, what you are requesting including the population of patients and timeframe needed:

What is the relationship to the patients whose records are being requested? (for example, provider/patient relationship)

What is the purpose of the requested information/how will it be used?

How would you like to receive the information? (ie: flat file, CCD exchange)

Additional Comments