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Online Request of Medical Record Information

Please complete the below form to request your Medical Information from KSB’s Health Information Management Department.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Date of Birth *

Date(s) of Visit(s)

Name of Facility or Provider *

Fax Number

Email (If Requesting Electronic Format)

Please Check Both Boxes: *

Signature *

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