Get Access Form - Oregon Health & Science University - Ohsu

This guide provides comprehensive instructions for completing the Access Form at Oregon Health & Science University. By following these steps, users will ensure that their amendment requests are accurately submitted and processed.

Follow the steps to fill out the Access Form effectively.

1. Use the ‘Get Form’ button to access the Access Form and open it in your chosen format for completion.
2. In Section A, begin by providing your personal information. Fill in your last name, first name, and middle name as they appear on official documents.
3. Enter your current address, ensuring it is complete and accurate for correspondence.
4. Provide your telephone number, making sure to include the area code.
5. Fill in your birth date using the format requested in the form.
6. Locate your medical record number and include it in the designated field.
7. In the request section, describe or attach a copy of the health information you wish to amend, including the name of the provider, date(s) of service, and specific details about the information.
8. State how you would like the health information amended, providing clear and concise instructions.
9. Indicate your reasons for the requested amendment, being as specific as possible.
10. If applicable, specify individuals or organizations who should be notified of the amendment if accepted—include their names, addresses, and phone numbers.
11. Sign and date the form, ensuring that any legal representatives also print their names if necessary.
12. After completing the form, review all entries for accuracy, then save your changes. You may print, share, or download the final version for your records.

Complete the Access Form online to ensure your health information is accurately represented.