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Please complete, signandreturnthisform, with youroriginalsignatureto: MedicalRecordsClerk BerksCommunityHealthCenter 645PennStreet,Suite301 Reading,PA19601Instructions YouhavetherighttorequestthatBerksCommunityHealthCenter(BCC)amendorcorrectthemedicalinformationcontainedin your
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Start by reading the instructions on the form carefully.
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Provide your personal information such as name, address, and contact details in the appropriate fields.
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Clearly state the amendment you are requesting and provide any necessary supporting documentation.
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If applicable, indicate the date of the original filing and provide any relevant details about the filing.
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Sign and date the form at the designated area.
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The form rev12-28-16-request for amendment is needed by individuals, businesses, or organizations who wish to make changes or corrections to previously filed documents or records. It is commonly used in legal, administrative, or regulatory processes where amendments to official records or filings are required.
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Form rev12-28-16-request for amendment is a form used to request changes or updates to previously submitted information.
Any individual or entity that needs to amend information previously submitted must file form rev12-28-16-request for amendment.
Form rev12-28-16-request for amendment can be filled out online or in person by providing accurate and updated information.
The purpose of form rev12-28-16-request for amendment is to ensure that all information on file is accurate and up to date.
All relevant information that needs to be amended or updated must be reported on form rev12-28-16-request for amendment.
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