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Medical Record Discrepancies
This form is for Medical record discrepancies only. Please allow up to 30 days for a response.
	Patient Name
*	Last Name
*	First Name
*	Middle Initial
*	Date of Birth
	Service Details
*	Date of Service
*	Facility of Service	Russell County HospitalFamily Practice Assoc of RCSurgical Assoc of RC
	Person to Contact
*	First Name
*	Last Name
*	Phone
*	Describe Discrepancy