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REQUEST FOR DESIGNATED RECORD SET Last Name First Name MI Date of Birth Phone Number Release records from (please select one) Specific clinic×provider: Address:
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Fill in your personal information, including your name, address, and contact details.
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Provide details about the specific request you are making, such as the reason for the request and any supporting documentation you may have.
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Follow any additional instructions or prompts on the form, such as providing specific dates or details related to your request.
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If necessary, print a physical copy of the form for your records or to submit it via mail.
Overall, anyone who needs to make a request or submit relevant information to a specific department or organization can benefit from using the drs requestdocx form. It may be used by individuals, businesses, or institutions that require specific documentation or assistance from the department or organization in question.
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