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Get Request To Access Health Information Form - Alberta Health And ...

Instructions for completing this form are on the back. Mr. Mrs. About you Ms Miss Dr. Last name First name Mailing address City or town Telephone (business) ( ) Province Telephone (home) ( ) ( ) Date of Birth (day/month/year) Other Fax number ( ) Postal code E-mail address 1. Please attach the initial fee of $25.00. About your request 2. To which custodian are you making your request? (Please fill in the name of the individual or organization.) 3. Do you want to: (a) recei.

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