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Sample Record Request Form

DATE ____________________________________________________________

NAME ____________________________________________________________

ADDRESS _________________________________________________________

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PHONE NUMBER __________________________________________________

DESCRIPTION OF RECORDS (For more space, continue on back) __________

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__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

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INSTRUCTIONS: PICK-UP/FAX/MAIL/DISK/EMAIL

SIGNATURE (When request is fulfilled) __________________________________

For Office Use Only:

Copies ____ Postage ____ Disk ____ Fax ____

TOTAL COST ______________

DATE REQUEST FULFILLED ____________

INITIALS OF STAFF MEMBER ______________

DATE INFORMATION: Picked up ____ Faxed ____ Mailed ____