ࡱ> ')&5@ bjbj22 XX tttt  / &{   $UR:  {{  ` ` ` " ` ` ` r r  h?4;t "r 0/ r  r  r <3 h` T   J   GASTROENTEROLOGY CENTER OF NEVADA and ENDOSCOPY CENTER OF SOUTHERN NEVADA RECORDS REQUEST FORM Patient Access to the Medical Record Request Form TO PROTECT YOUR PRIVACY AND TO PREVENT IMPROPER DISCLOSURE, YOU MUST HAVE YOUR SIGNATURE NOTARIZED ON THIS FORM OR YOU MUST PROVIDE A COPY OF YOUR DRIVERS LICENSE ALONG WITH THIS REQUEST I, __________________________________, request the Gastroenterology Center of Nevada or Endoscopy Center of Southern Nevada to make copies of my medical records for me or for my personal representative, ____________________. I understand that these records contain protected health information (PHI). I agree to be responsible for the cost of copying these records in the amount of $.60 cents per page and postage Patient Printed Name and Date of Birth ______________________________________ Patient Address: ________________________________________________________ Patient Social Security Number: ____________________________________________ Patient Procedure Date____________________________________________________ Location of Procedure: ____________________________________________________ Purpose of Request:______________________________________________________ Date of request Patient Signature Address to which records are to be mailed: ____________________________________ ____________________________________ ____________________________________ NOTARY: Please indicate that you have verified the identity of the person requesting these records: OR, please attach a copy of your drivers license or other photographic identification. This form should be sent to: Gastroenterology Center of Nevada, PO BOX 35140, Las Vegas, Nevada 89133. UW_M N O ~ . 0 1 } ~  =     \ j k { <=[h0hTUM5hTUMh_ hlt\h# h#>* hlt\hlt\h#h 3hlt\,_M N > l / T y z { !W!!!!!!!!!!!!!!!!!!$a$gd#gdlt\  gdlt\gd#  $a$gdlt\$a$gdlt\gdlt\ =>!!!!!!/ =!"#$%H@H Normal CJOJPJQJ_HmH sH tH d@d Heading 1#$$&d@&Pa$5CJ KH OJQJL@L Heading 2$xx@&5CJOJQJL@L Heading 3$<@&5CJOJQJ>@> Heading 4$$@&a$58@8 Heading 5$@&5DAD Default Paragraph FontViV  Table Normal :V 44 la (k(No List F%@F Envelope Return CJOJQJ_MN> l /Tyz{=>0(@00@0p0@0@0p@0@0@0@0@0@0p@0p@0@0@0@0@0p@0p@0@0p0@0@0@0@0p@0@0@0pNlOy00Oy00Oy00Oy00Oy00   8@0(  B S  ?KItmp>> 8T?@At&&0CC !!/66II i*urn:schemas-microsoft-com:office:smarttagsState0http://www.5iamas-microsoft-com:office:smarttags=*urn:schemas-microsoft-com:office:smarttags PlaceType= *urn:schemas-microsoft-com:office:smarttags PlaceNameV *urn:schemas-microsoft-com:office:smarttagsplacehttp://www.5iantlavalamp.com/     ~{3UW  //TT=>wtest x 0 3'CTUMlt\#U_@C 44@@UnknownGz Times New Roman5Symbol3& z Arial3z Times;& z Helvetica"qh&dž  24d3qH(?lt\    testOh+'0`   ( 4@HPX s s s s sNormaltestl2stMicrosoft Word 10.0@G@ S@4);՜.+,0      V A  Title  !"#$%(Root Entry FНK4;*1Table WordDocumentSummaryInformation(DocumentSummaryInformation8CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q