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TX Integrity Rehab Medical Records Request 2016 free printable template

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PLEASE COMPLETE THIS FORM AND SUBMIT IN CLINIC, FAX TO 2545268604, OR SEND VIA EMAIL TO MSWARTZBAUGH INTEGRITYREHAB.NET NAME: DATE OF BIRTH: PATIENT AT INTEGRITY BETWEEN: and MONTH / YEAR PLEASE CHECK
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TX Integrity Rehab Medical Records Request Form Versions

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TX Integrity Rehab Medical Records Request 2017
4.1 Satisfied (48 Votes)
TX Integrity Rehab Medical Records Request 2016
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How to fill out TX Integrity Rehab Medical Records Request

01
Obtain the TX Integrity Rehab Medical Records Request form from the clinic's website or front desk.
02
Fill in your personal details, including full name, date of birth, and contact information.
03
Specify the dates of service for which you require medical records.
04
Indicate the specific documents you are requesting (e.g., progress notes, discharge summaries).
05
Provide the name and address of the individual or entity that will receive the records.
06
Sign and date the form to authorize the release of your medical records.
07
Submit the completed form to the clinic via fax, email, or in-person.

Who needs TX Integrity Rehab Medical Records Request?

01
Patients seeking access to their own medical records.
02
Family members or legal representatives of patients who need to obtain records on their behalf.
03
Healthcare providers requiring previous medical records for continuity of care.
04
Insurance companies needing records for claim processing or audits.
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TX Integrity Rehab Medical Records Request is a formal document that allows patients or authorized representatives to request access to medical records from TX Integrity Rehab.
Patients or their legal representatives are required to file the TX Integrity Rehab Medical Records Request to obtain their medical records.
To fill out the TX Integrity Rehab Medical Records Request, provide accurate personal information such as name, date of birth, and the specific records requested. Additionally, include contact information and the signature of the patient or authorized representative.
The purpose of the TX Integrity Rehab Medical Records Request is to ensure that patients can access their medical records for personal review, continuity of care, or to provide information to other healthcare providers.
The information that must be reported on the TX Integrity Rehab Medical Records Request includes the patient's full name, date of birth, the specific medical records being requested, the dates of service, contact information, and the signature of the patient or legal representative.
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