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EAR, NOSE & THROAT Michael Friedman, MD, FACS T.K. Venkatesh, MD, FACS A Division of Adam Levy, MD Kathryn Colman, MD I hereby authorize: Dr. Michael Friedman, Medical Director Sarah Felt, PAC 3000
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How to fill out the medical records request form at the Chicago Sleep Center for a patient:
01
Obtain the medical records request form from the Chicago Sleep Center. This form is typically available on their website or can be requested from their administrative office.
02
Start by providing the patient's personal information, such as their full name, date of birth, address, and contact details. This information is necessary for the Chicago Sleep Center to correctly identify the patient and retrieve their medical records.
03
Indicate the purpose for which the medical records are being requested. Specify if it is for personal review, legal purposes, or for a healthcare provider. Including this information helps the Chicago Sleep Center understand the intent behind the request.
04
Mention the specific dates or time period for which the medical records are being requested. It is important to be as precise as possible to ensure that the relevant records are accessed.
05
Specify the preferred format for receiving the medical records. Options may include electronic copies, physical copies, or both. Ensure to provide valid contact information if electronic records are preferred.
06
Sign and date the medical records request form. This signature confirms that the patient or their authorized representative is requesting access to the medical records.

Who needs the medical records request form at the Chicago Sleep Center:

01
Patients requiring their own medical records for personal review or to share with another healthcare provider.
02
Legal representatives or attorneys requesting medical records for legal proceedings.
03
Other healthcare providers involved in the patient's care who require the medical records for continuation of treatment.
The medical records request form at the Chicago Sleep Center ensures that only authorized individuals have access to a patient's medical information, ensuring privacy and security.
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This form is used to request medical records from the Chicago Sleep Center for a specific patient.
Anyone who needs access to the medical records of a patient at the Chicago Sleep Center.
You can fill out the form by providing the patient's information, specifying the records needed, and signing the authorization.
The purpose of this form is to request medical records for a specific patient from the Chicago Sleep Center.
The form should include the patient's name, date of birth, medical record number, date of the records needed, and the reason for the request.
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