Provide your full name, date of birth, and a phone number where you can be reached during business hours.
Complete the numbered blanks as follows:
- Enter the name of the organization/facility/person with the information to be disclosed. If this is not Christie Clinic, provide the full address in "Section A".
- Enter the name of the organization/facility/person you want the records sent to. Again, provide the full address if this is not Christie Clinic in "Section B".
- Indicate specifically which records you want to have copied in the black lined box.
- State the purpose for your disclosure. Examples: claim determination, workers comp. case, attorney, personal request in "Section C".
- Date and sign at the bottom of the form.
If you have questions, please call 217.366.9656 for assistance.