CERTIFICATION OF MEDICAL RECORDS
CERTIFICATION OF MEDICAL RECORDS
Patient Name: __________________________________________________________________
I certify that the documents attached to this certificate, consisting of ___________ pages, are accurate and complete duplicates of the original medical records of the patient listed above for the following period of time:
_____________________________________ to ______________________________________
Exclusions:
None
As follows: __________________________________________________
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Certification of No Records: A thorough search of our files, carried out under my direction, revealed no documents, records or other materials called for in the medical records request.
I further certify that the produced records are a true copy of ALL the records requested and are kept in the course of regularly conducted activity.
Executed on this _________ day of _______________________, _________
______________________________________________________________ Records Custodian (signature)
________________________________________________________________ Printed Name of Records Custodian
_______________________________________________________________ Name of Facility or Practice (Please Print)
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- california medical malpractice sample exemplars forms
- records management and
- texas hipaa medical release form welcome to nginx
- sample forms letters omti
- certification of medical records
- medical records request fee
- sample prove up and questions
- sample letter for public schools
- responses to request for medical records
- this sample is provided as a model agreement and
Related searches
- tampa general medical records fax
- humc medical records department
- medical records jobs at home
- medical records tampa general hospital
- tgh medical records request
- jfk medical records edison nj
- medical records release form printable
- florida hospital medical records portal
- hackensack medical records fax number
- list of medical certification programs
- medical records hackensack medical center
- ocean medical center medical records fax