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PATIENT REQUEST FOR ACCOUNTING OF DISCLOSURES (100/CASE)


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Item Number: W-HIP106
THE PATIENT WHO REQUESTS AN "ACCOUTING OF DISCLOSURES" WILL BE ASKED TO COMPLETE THIS FORM THAT REQUIRES THE PATIENT TO PROVIDE THE PURPOSE OF THE REQUEST, THE DATED REQUESTED, ETC. THE FORM, RETAINED IN THE PATIENT'S MEDICAL RECORD, ALSO ALLOWS YOU TO RECORD THE DATE YOU COMPLY WITH THE REQUEST.
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