CD-ROM: Confirm Receipt / Request Password
Your Name *
Your answer
Datalink ID Number *
Located on the CD-ROM or Subject line of the email you received.
Your answer
Your Phone Number *
In case we require further verification
Your answer
Your Email Address *
A valid email address is required to receive the password. Personal email addresses cannot be used unless you are the patient. If you do not have a company email you may enter your corporate website address.
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Your Fax Number *
Your answer
Check The Appropriate Box *
Required
Check The Box to Agree With The Statement Below *
Required
How Do You Prefer To Receive Medical Records From Us In The Future?
Your Position *
If you are the patient type "NA"
Your answer
Name of Organization *
Please write the name of the business or medical facility to whom the envelope is addressed. If you are the patient type "SELF".
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