Medical Record Review Form

Please know that we strive to respond to these requests in a reasonable time frame. Due to the nature of your requesting an amendment and our subsequent review of your medical record, please know that this review process can take up to 60 days. If the review will take more than 60 days, you will receive a written notice indicating the reason for the delay and the date by which the review will be completed. Please also be aware, based on the results of our review, that we may or may not be able to make changes to the legal medical record.

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