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2020-10-20T11:16:31-04:00
COSM Medical Records Request Form
Please Use This Form To Submit Medical Record Requests.
Please allow 10 Business Days for Processing.
If You Need Records Expedited, Please Call Our Office at
201-500-9450
.
Patient Name
*
First
Patient Date Of Birth
*
MM slash DD slash YYYY
Requestor Name
*
First
Requestor Company
*
Requester Phone
*
Requestor Fax
*
Requestor Email
*
PLEASE UPLOAD AN AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION OR YOUR REQUEST WILL NOT BE PROCESSED.
*
Accepted file types: pdf, Max. file size: 5 MB.
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