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Get Address To Send Accounting (if Different From Above And Accounting Is To Be Mailed)

URES 45 CFR 164.528; 45 CFR 5b.9(c) DATE OF REQUEST PATIENT NAME HEALTH RECORD NUMBER DATE OF BIRTH PATIENT ADDRESS ADDRESS TO SEND ACCOUNTING (If different from above and accounting is to be mailed) I would like an accounting of disclosures for the following time frame: From: To: If you are only seeking an accounting of a certain type(s) of disclosure or disclosures to a specific person/entity, please describe the disclosures for which you are seeking an accounting: I understand that t.

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