The form can be ordered through supply channels. You may wish to review CIPS if you are requesting the return of records which were originally retired by your facility. Do not distribute for individual personal use. Contact the Records Management Officer to obtain shipment information for inclusion in item 9, Remarks, if the request is for a record originally retired by your facility. Submit the original and one copy.
All entries relate to patient status at time of treatment.
To expedite the receipt of requested records, you must complete items 1-10 and 19 as specified below. Incomplete forms will be returned. Provide the places of treatment, especially the name of the facility that had last responsibility for the record. Check with your Records Management Officer. Enter all information, as appropriate.