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First Name: [REQUIRED]
 
Last Name:
E-Mail: [REQUIRED]
 
Phone:
Medical Group (if applicable):
Date of Birth (patient requests) (MM/DD/YYYY) :
 
Comments: [REQUIRED] 
    I understand I should NOT send medical requests requiring prompt attention as this form is sent to EPIC's administrative office. Forms are only checked periodically during weekday business hours and can take 2-3 days for a response.