Request To Access Medical Records Form Page 3
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3Table A - List of requested documents
□
entire medical record;
or
□
all documents relating to the diagnosis/treatment of the following condition/s;
(please briefly describe condition/s)
1.
2.
3.
4.
5.
and/or
□
the following documents:
(please describe documents requested)
1.
2.
3.
4.
5.
Signed
Patient or parent/guardian of patient
Date
Please fill out below, If applicable
Signature of person authorised to be
given access to patient’s medical record
Date
PAGE 3/3
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