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PDMPTHESTATEALASKAofFOR DIVISION USE ONLY DO NOT KOFAXDepartment of Commerce, Community, and Economic Development Division of Corporations, Business and Professional LicensingPrescriptionDrugMonitoringProgram(PUMP)

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How to fill out patient request for record

01

Obtain the appropriate form for requesting medical records from the healthcare provider.

02

Fill out the patient information section completely and accurately, including full name, date of birth, and contact information.

03

Specify the records being requested and the purpose for which they are needed.

04

Sign and date the form to certify that the request is being made by the patient or their authorized representative.

05

Submit the completed form to the healthcare provider either in person, by mail, or via fax, as instructed.

06

Follow up with the healthcare provider to ensure that the request is being processed in a timely manner.

Who needs patient request for record?

01

Patients may need to request their own medical records for various reasons, such as seeking a second opinion from another healthcare provider, participating in a research study, or keeping personal health records up to date.

02

Authorized representatives, such as family members or legal guardians, may also need to request patient records on behalf of the individual.

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What is patient request for record?

Patient request for record is a formal request made by a patient to obtain a copy of their medical records.

Who is required to file patient request for record?

The patient or their authorized representative is required to file a patient request for record.

How to fill out patient request for record?

To fill out a patient request for record, the patient or their authorized representative needs to complete a form provided by the healthcare provider, providing necessary personal information and specifying the records requested.

What is the purpose of patient request for record?

The purpose of patient request for record is to allow patients to access their own medical information, review their medical history, and share it with other healthcare providers if needed.

What information must be reported on patient request for record?

Patient request for record must include the patient's full name, date of birth, address, contact information, and details of the records requested.

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