Get Kleinert Kutz Medical Records Form
F I am notified in writing of the extension. I further understand that my rights are limited to any information in my designated record set as defined in section 164.501 of the Code of Federal Regulations. By signing below, I acknowledge and agree to the above conditions. Signature of patient or designated Representative Date Guidelines: Charges and cost for copying medical records Patients are entitled to one.
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- Use the e-signature tool to e-sign the template.
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- Click Done and save your new document.
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