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Request For Patient Access To Medical Records

I hereby request (name of physician, hospital or other healthcare provider)___________________ , to give me access to medical information for (patient’s name)________________________. SCOPE OF ACCESS REQUESTED G All the records or I would like access to: G The portion of the records concerning: ________________________________________________________________ (Specify type of disease, accident, dates of treatment, other portion of [...]

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Release Of Medical And Psychiatric Records

Authorization For Release Of Medical Records __________________________________ (name of hospital) Patient’s Name and Address: _________________________________________ Social Security Number: __________________________ Birth Date: __________________ I authorize you to release to the persons listed below information concerning the medical and psychiatric evaluation and treatment received by the above named patient at ________________________ (name of hospital) during the approximate [...]

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Power of attorney for healthcare

Notice to Person Making this Document You Have The Right To Make Decisions About Your Health Care. No Health Care May Be given To You Over Your Objection, And Necessary Health Care May Not Be Stopped Or withheld If You Object. because Your Health Care Providers In Some Cases Have Not Had The Opportunity To [...]

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