Participant Record Request

Record Request

Pace Participant
Please use this form to request records from Pace Center for Girls (Pace). To ensure timely processing, please provide complete and accurate information. All requests will be reviewed and fulfilled in accordance with applicable laws and policies.
- Authorization to Use Jotform to Obtain and Release Information
  
  Pace uses Jotform, a web-based form creator, to collect and process requests for participants' records. Pace has implemented reasonable measures to protect Personal Health Information (PHI) as defined by HIPAA and other confidential information, including encryption and other security protocols. Jotform also maintains security practices designed to protect information submitted through this platform.
  
  By submitting this record request form, you acknowledge that your information will be transmitted and stored electronically through Jotform for the purpose of processing this request.
- Signature
- Date
  
  MonthDayYear
  Date
- Name of person submitting the request
  
  First NameLast Name
- Name of the organization or person to whom the information will be disclosed
- Relationship to Pace participant
- Please upload proof of identity
  
  Cancelof
- Preferred contact method
- Phone number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Participant's name while attending Pace
  
  First NameLast Name
- Most recent Pace location attended
  (Most recent Pace Center attended, if multiples)
- Program attended (Select all that apply)
- Type of request:
- Purpose of the disclosure:
  
  Other
- If other purpose for disclosure, please briefly describe.
- Please upload the 'Release of Information' form, if applicable.
  
  (Upload any authorization to support this request.)
  Cancelof
- Please select the type of information requested:
  
  Other
- If other type of information, please briefly describe.
- Delivery method
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Any additional notes about this request?
- I certify that I am authorized to request these records and that the information provided is accurate and complete to the best of my knowledge.
  
  I authorize Pace to process this request and access, use, and disclose the information necessary to fulfill it.
  
  I understand that records will only be released in accordance with applicable privacy laws and organizational policies.
- Signature
- Submission date
  
  MonthDayYear
  Date
- Record Request ID
Should be Empty: