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Get Patient Portal Access / Proxy Form - Bothwell Regional Health Center

Authorization/Declination for Access to Patient Portal Bothwell Regional Health Center (Please Print) Patient Name: Date of Birth: Patient Email Address: Patient Phone Number: Proxy Email Address:.

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  1. Open the template in our full-fledged online editing tool by clicking on Get form.
  2. Fill out the necessary fields that are yellow-colored.
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  5. Insert the date.
  6. Read through the entire e-document to make sure you haven?t skipped anything important.
  7. Hit Done and download the new template.

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