Fillable request dhh emails form

Description
Louisiana Department of Health and Hospitals Access to Records Request Form Name: Mailing Address: City/State/Zip: Request Date: Date of Birth: Medicaid ID# or Soc. Sec.#: See Reverse for Your Rights to Access Health Information I want to access, inspect and obtain information about my health information as marked below: r I would like to Review my record. r I would like a Copy of my record. (From: ___ To: ___) r...
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request dhh emails
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