advancedmedrec Patient File Release

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Advanced Medical Records Inc.

979.220.0060

                                                  Comments/Feedback:           Company Info/Questions:
                                                          The AMR Team                    John Cangelose - Managing Partner
                                               contactus@advancedmedrec.com         jcangelose@advancedmedrec.com

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Requestor Name

Physician Name*

Practice Name*

Address*

City*

State *

Zip

Files Ready by Date*

Time

Number of Files

Contact Name at Facility*

Contact Phone Number*

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