Below are two options on how to fill out the form, please read each option.
Option One
Forms can be printed and hand carried.
Option Two
Forms can be filled out and submitted via e-mail IF Adobe Reader used on the computer or mobile device. If PDF opens in a new window, download the form and open it in Adobe Reader. After the form is downloaded to your device, open it with Adobe Reader. In the form you will see fillable areas highlighted in a light blue. Click within this area to add information.
PDF documents on this page require Adobe Reader to view and to fill. You may obtain Adobe Reader for free from the Adobe website by clicking the icon. If you already have Adobe Reader installed on your computer, you do not need to install it again.
REL Data Collection Form*
*This information in the Race, Language, Ethnicity Form is required by payers and government programs. You have the right to decline this information.