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INTELLIGENT QUESTIONNAIRE FOR

REQUEST TO INSPECT AND COPY PATIENT RECORDS - $9.95

PRINT YOUR DOCUMENT IN MINUTES AFTER ANSWERING THE QUESTIONS BELOW!  

INFORMATION REGARDING PATIENT / PATIENT'S REPRESENTATIVE
 
Patient's First Name:
FAQ
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Patient's Last Name:

Who is requesting to inspect/copy
the medical records?
Patient's Phone Number: - -

Representative's First Name:
Representative's Last Name:
Representative's Phone Number: - -
 
INFORMATION REGARDING ENTITY OR PERSON THAT HAS PATIENT'S MEDICAL INFORMATION
 
Name:
     CompanyCompany Name:
  PersonFirst Name:
   Last Name:
Address:
City:
State: Zip Code:
 
MEDICAL RECORDS TO INSPECT / COPY
 
What patient records are you requesting?
FAQ
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Description of Specific Records:  
Patient Records (in format MM-DD-YYYY)FROM - -     TO - -  
 
Do you require these patient records for an appeal for eligibility for a public benefit program?   
 
 
 
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the form
If you want to
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