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Southeast Colorado Hospital

Electronic Medical Records Request

Please complete form to receive patient medical records. Please also indicate your preferred delivery method.
Patient #1
  Name
  Phone Number
  Date of Birth
  Visit Date
  Documents Requested: ER Visit
X-ray
Labs
H&P
Discharge Summary
Other
 
if other please list
Patient #2
  Name
  Phone Number
  Date of Birth
  Visit Date
  Documents Requested: ER Visit
X-ray
Labs
H&P
Discharge Summary
Other
 
if other, please list
Patient #3
  Name
  Phone Number
  Date of Birth
  Visit Date
  Documents Requested: ER Visit
X-ray
Labs
H&P
Discharge Summary
Other
 
if other please list
Patient #4
  Name
  Phone Number
  Date of Birth
  Visit Date
  Documents Requested: ER Visit
X-ray
Labs
H&P
Discharge Summary
Other
 
if other please list
  Preferred Delivery Method