Merge Request Form

Submit this form to request merges of patient records.

Requesting Facility:
Requestor
Requestor Email

Please enter a valid email address to receive notification on updates to your ticket.
Requestor Phone Number
Patient/Record #1 (Record to be retained)
Name Name First Middle Last
Date of Birth Date of Birth / MM / DD YYYY
Medical Record Number:
Patient/Record #2
Name Name First Middle Last
Date of Birth Date of Birth / MM / DD YYYY
Medical Record Number:
Patient Record #3
Name Name First Middle Last
Date of Birth: Date of Birth: / MM / DD YYYY
Medical Record Number:
Additional Details or Comments:
By signing this form, the [PERFORMING FACILITY REFERENCED ABOVE] representative requests RAPC to make the requested changes in the patient record. The [PERFORMING FACILITY REFERENCED ABOVE] is solely responsible for the accuracy of the information on this form. The [PERFORMING FACILITY REFERENCED ABOVE] further acknowledges that the requested changes are being made solely at the request of the [PERFORMING FACILITY REFERENCED ABOVE] and are not the result of any error or omission by RAPC or any RAPC employee or agent. In addition, the [PERFORMING FACILITY REFERENCED ABOVE] is solely responsible for any additional communication to affected parties as the result of the request, to include and not limited to the patient, providers, or payers.

Draw or Type

Clear

Full Name
Requestor Name: Requestor Name: First Last
Date Date / MM / DD YYYY