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PATIENT RECORDS REQUEST FORM Please Send Records To: Shannon Dental Health Center 800 N. Center Parkway Kennewick, WA 99336 pH: 5097830824 Fax: 5097839136 Patient(s) Whose Records Are Being Requested
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What is patient records request form?
The patient records request form is a document used to request access to or copies of a patient's medical records.
Who is required to file patient records request form?
Patients or their authorized representatives are required to file the patient records request form.
How to fill out patient records request form?
To fill out the patient records request form, the patient or authorized representative must provide their personal information, details of the records requested, and sign and date the form.
What is the purpose of patient records request form?
The purpose of the patient records request form is to obtain access to or copies of a patient's medical records for personal use or to provide to another healthcare provider.
What information must be reported on patient records request form?
The patient records request form must include the patient's name, date of birth, contact information, specific records requested, and any relevant authorization to release the records.
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