Record Request Dialysis Access Center, Inc.

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Request Medical Records

Requesting Physician Information

Physician Name (First & Last) *

Name of Person Requesting Records *

Office Number (Area code first, no spaces) *

Fax Number (Area code first, no spaces) *

E-mail Address *

Records Requested *

Patient Information

First Name *

Last Name *

Date of Birth (mm/dd/yyyy) *

Last four digits of Social Security # *

Additional Information

Please send the medical records by: *

Would you like a follow-up e-mail? *


* = Required Fields

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