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    Request Form

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    Meycauayan Dialysis
    The document is a request form from the City of Meycauayan Dialysis Center's Medical Records Section to provide clinical records for a patient, including laboratory tests, medical certificates, clinical abstracts, and treatment sheets. The requesting party must indicate the purpose of the request, their relation to the patient, and provide authorization and valid identification. The attending physician must also approve the request.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Request Form

    Uploaded by

    Meycauayan Dialysis
    30 views1 page
    The document is a request form from the City of Meycauayan Dialysis Center's Medical Records Section to provide clinical records for a patient, including laboratory tests, medical certificates, clinical abstracts, and treatment sheets. The requesting party must indicate the purpose of the request, their relation to the patient, and provide authorization and valid identification. The attending physician must also approve the request.

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    request form

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    The document is a request form from the City of Meycauayan Dialysis Center's Medical Records Section to provide clinical records for a patient, including laboratory tests, medical certificates, clinical abstracts, and treatment sheets. The requesting party must indicate the purpose of the request, their relation to the patient, and provide authorization and valid identification. The attending physician must also approve the request.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    30 views1 page

    Request Form

    Uploaded by

    Meycauayan Dialysis
    The document is a request form from the City of Meycauayan Dialysis Center's Medical Records Section to provide clinical records for a patient, including laboratory tests, medical certificates, clinical abstracts, and treatment sheets. The requesting party must indicate the purpose of the request, their relation to the patient, and provide authorization and valid identification. The attending physician must also approve the request.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    CITY OF MEYCAUAYAN DIALYSIS CENTER

    Sitio Bulac Road, Malhacan, Meycauayan, Bulacan

    Subject: Request for Clinical Records of the Patients:


    To: Medical Records Section:

    Request that the following information be furnish about

    MR./MRS. /MAST. /MIST. __________________________________________________

    1. Laboratory Test
    2. Medical Certificate
    3. Clinical Abstract
    4. Treatment Sheet

    The purpose of this record is for: _______________________________

    _________________________ Certified & Approved


    Requesting party

    _________________________ _____________________
    Relation to the patient Attending Physician

    NOTE: Please follow up on: ___________


    Contact Person: _______________

    Authorization Letter
    Any Valid ID

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