HelloNote

Data Removal Request Form


HelloNote Data Removal Request
I, , hereby authorize HelloNote (E Medical Records Live Inc.) to
archive the following information. I acknowledge that this cannot be undone and I have the authority to
make this decision.


Data to be removed:
Patient ID:

Case name:  

Case date:  

Note number and type:  

Note date:  

Reason for removal:  


Remove (Select): 

 


Requestors information:
Date of request: April 19, 2024

Clinic name:


Your name (first, middle initial, last):


Thank you.

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Data Removal Request Form
lock iconUnique Document ID: 73f9c48fdcc33beccbd763332282b50299bc895b
TimestampAudit
October 29, 2021 4:42 pm EDTData Removal Request Form Uploaded by HelloNote EMR - hello@hellonote.com IP 100.38.101.240
April 18, 2023 5:39 pm EDTLiza - Liza@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 54.227.17.134
April 18, 2023 5:39 pm EDTSteve - steve@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 54.227.17.134
April 18, 2023 5:52 pm EDTLiza - Liza@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 54.227.17.134
April 21, 2023 8:03 pm EDTLiza - Liza@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 54.227.17.134
April 21, 2023 8:04 pm EDTLiza - Liza@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 54.227.17.134
September 29, 2023 11:44 am EDTLiza Stunis - liza@hellonote.com added by HelloNote EMR - hello@hellonote.com as a CC'd Recipient Ip: 100.38.101.240
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