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Request Form

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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Meycauayan Dialysis
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77 views1 page

Request Form

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.

Uploaded by

Meycauayan Dialysis
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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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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