Duplicate Multiple Record Correction
Please enter required fields indicated by *
Requestor's Name *
Telephone Number *
(
)
-
E-mail *
CAIR Org ID *
CAIR Username *
Patient Information
Record A
Cair ID *
First Name *
Last Name *
DOB *
Record B
Cair ID *
First Name *
Last Name *
DOB *
Add more patients to merge
Record A
Cair ID *
First Name *
Last Name *
DOB *
Record B
Cair ID *
First Name *
Last Name *
DOB *
Add more patients to merge
Record A
Cair ID *
First Name *
Last Name *
DOB *
Record B
Cair ID *
First Name *
Last Name *
DOB *
Electronic Signature
By checking this box and entering your name below, you confirm that the listed records are for the same patient under your care and that you are requesting these records be merged into a single patient record. Please note that the merge process is not reversible so it is your responsibility to ensure the patients records listed are indeed the same patient.
Full Name *
Date *
* THIS AUTHORIZATION EXPIRES NINETY (90) DAYS AFTER IT IS SIGNED
