Records Request
I authorize and request the disclosure of all protected information for the purpose of review and evaluation in connection with a legal claim. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:
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Email *
Patient Name *
Date of Birth *
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Requested Records *
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Where would you like records forwarded to? Please include recipient name, address and/or email if applicable.  *
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