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Request for Incident Records  Form

Request for Incident Records Form

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Person to whom the PHI should be sent and where the PHI should be sent. Generally we will provide you or your authorized representative access to your PHI within thirty 30 days of your request. We may verify the identity of any person who requests access to PHI as well as the authority of the person to have access to the PHI by asking the requestor to provide the patient s social security number date of birth legal authority to act on behalf of the patient such as a power of attorney or other...
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