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MRD Requisition Form

The document is a Medical Records Department (MRD) requisition form used to request copies or summaries of a patient's medical records. It includes fields for patient information, signatures from the medical superintendent, MRD technician, patient, and receiver. The form ensures proper authorization and documentation for the release of medical records.

Uploaded by

Neeru Soni
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918 views1 page

MRD Requisition Form

The document is a Medical Records Department (MRD) requisition form used to request copies or summaries of a patient's medical records. It includes fields for patient information, signatures from the medical superintendent, MRD technician, patient, and receiver. The form ensures proper authorization and documentation for the release of medical records.

Uploaded by

Neeru Soni
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

MRD REQUISITION FORM

TO: DATE :

I REQUEST THAT COPIES OR SUMMARIES OF THE MEDICAL RECORDS O MY PATIENT:

BE RELEASED TO:

PATIENT NAME:

UHID/IPD:

ADDRESS:

SIGNATURE OF MEDICAL SUPERINTENDENT SIGNATURE OF MRD TECHNICIAN

SIGNATURE OF PATIENT SIGNATURE OF RECEIVER WITH DATE

(RELATION WITH PATIENT)

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