Request for Private Medical Information A4254-DA
Form Template
The Request for Private Medical Information A4254-DA mobile app provides a simple way to manage medical information requests electronically.
5,000 Companies save time and money with GoCanvas
Easily accessible from a smartphone or tablet, the app allows the requesting party to submit official records requests to the appropriate health care location.
The electronic authorization form includes information about the medical records needed, including patient name and birth date, specific medical records required and reasoning and other relevant details. If approved, the app has the capability to capture a signature for authorization.
Not quite right?
GoCanvas accounts come
with hundreds of form templates
Don't take our word for it...
“I’m not a tech guy and I was able to pick this thing up in probably an hour, and actually start to build apps. I’ve done them over lunch when I’ve gotten frustrated with a process that didn’t exist in our company. So for non tech people who’ve got a problem, the support here is awesome and I’d recommend it to anybody, not just in our industry.”
