Data Removal 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: February 3, 2023

Clinic name:

Your name (first, middle initial, last):

Thank you.

Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: Data Removal Form
lock iconUnique Document ID: 632c2244577fc85badc08af97703b09c22b65aa0
Timestamp Audit
November 4, 2021 1:08 pm ESTData Removal Form Uploaded by HelloNote EMR - hello@hellonote.com IP