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This section PHARMACY USE ONLY: Approved Not Approved (sent to HIM for verification) Harm/Date ___ Kickapoo Tribal Health Center Pharmacy Win Rx Connect/Rx2Go App REQUEST TO ADD FAMILY MEMBER(S) Win
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01
Open the rx2go-patient-family-member-requestpdf file on your device.
02
Fill in the patient's full name in the designated field.
03
Provide the patient's date of birth in the appropriate format.
04
Enter the patient's address, including street, city, state, and ZIP code.
05
Fill in the contact information of the patient, including phone number and email.
06
In the family member's section, write the full name of the family member making the request.
07
Provide the family member's relationship to the patient.
08
Enter the family member's contact information as well.
09
Indicate the reason for the request in the specified area.
10
Sign and date the document at the bottom.

Who needs rx2go-patient-family-member-requestpdf?

01
Patients who want a family member to request medication on their behalf.
02
Family members looking to assist patients in accessing their prescriptions.
03
Caregivers responsible for managing a patient's medication needs.
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rx2go-patient-family-member-requestpdf is a document used to request access to patient information or to designate a family member to receive specific healthcare information on behalf of the patient.
Patients or their legal representatives who wish to authorize a family member to access their medical records or health information are required to file the rx2go-patient-family-member-requestpdf.
To fill out the rx2go-patient-family-member-requestpdf, provide the patient’s personal information, the designated family member's information, and any specific details regarding the information access being requested, then sign and date the form.
The purpose of the rx2go-patient-family-member-requestpdf is to facilitate the legal authorization for family members to access medical information, ensuring the patient's privacy while allowing necessary information sharing.
The rx2go-patient-family-member-requestpdf must report the patient's full name, date of birth, contact information, the family member’s name and relationship to the patient, and the specific information being requested.
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