Get The Hospitals Of Providence Sierra Campus Access Request Form

Filling out The Hospitals Of Providence Sierra Campus Access Request Form online can help you easily request access to your medical records and other important information. This guide provides step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to complete the access request form online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by entering the patient’s name in the designated fields: Last name, First name, and Middle name. Ensure that the names are spelled correctly and completely.
3. Fill in the home address and home phone number of the patient. Providing accurate contact information is essential for effective communication.
4. Enter the patient’s date of birth in the specified format. This information helps to verify the patient's identity.
5. Record the date of the request. This date is important for tracking the timeline of your request.
6. Next, indicate what information you are requesting by checking all applicable boxes. Options include access to operating room notes, medical records, billing records, and any other records that contain personally identifiable information.
7. Select one of the options regarding the time period for requested information. You can choose to limit the request to a specific time frame or request all information maintained by the hospital.
8. If you prefer a summary of the requested information, check the appropriate box and note any associated cost.
9. Review the understanding section, which outlines your rights regarding the information requested, including details about denial and review options.
10. Indicate how you would like to receive the requested information, either electronically or on paper, by checking the appropriate box.
11. Specify if you would prefer to pick up the information or have it mailed to a designated address. Make sure to provide the mailing address if applicable.
12. Complete the payment information, including the cost per page for copying services and any additional explanations you may request.
13. Sign the form as the patient or a personal representative. Include the printed name and date for clarity.
14. Finally, review the completed form for accuracy, save your changes, then download, print, or share the completed form as needed.

Complete your access request form online today to obtain your important medical information.