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MEDICAL RECORD PRIVACY ACT STATEMENT This    GSA  Form

MEDICAL RECORD PRIVACY ACT STATEMENT This GSA Form

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9397 is used as a unique identifier to distinguish between employees with the same names and birth dates and to ensure that each individual s record in the system is complete and accurate and the information is properly attributed. DATE SYMPTOMS DIAGNOSIS TREATMENT TREATING ORGANIZATION Sign each entry HOSPITAL OR MEDICAL FACILITY STATUS DEPARTMENT/SERVICE SPONSOR S NAME SOCIAL SECURITY/ID NUMBER RELATIONSHIP TO SPONSOR PATIENT S IDENTIFICATION For typed or written entries give Name - last...
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