Get Ambulatory Care Center Access Request Form
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How to fill out the Ambulatory Care Center Access Request Form online
Filling out the Ambulatory Care Center Access Request Form is essential for requesting building access privileges via card readers. This guide will help you complete the form online, ensuring that you provide all necessary information accurately.
Follow the steps to fill out the form correctly.
- Click ‘Get Form’ button to obtain the form, which will then be available for you to complete in your preferred online editor.
- In the 'Requestor’s Name' field, enter your full name as the person making the request.
- Fill in the 'Date' field with the current date when you are submitting the request.
- Complete the 'Department' field with the name of your department to help identify the request's context.
- Provide your contact 'Phone' number to allow communication regarding the request.
- Enter your 'Fax' number if applicable, to facilitate document transmission if needed.
- Input your 'Email' address to receive confirmations and updates regarding the request.
- The 'Department Head Signature' section requires the signature of your department head, along with their name in the 'Department Head' field.
- If access to the gamma knife room is required, make sure that the 'Radiation Safety Officer' (currently Lily Lodhi) signs the indicated line.
- Select whether you are assigning or revoking access by checking either 'A' for assign or 'R' for revoke.
- Fill in the 'Access Effective Date' and 'Access Expiration Date' if applicable; otherwise, enter 'N/A'.
- In the 'TUid' field, type the unique identifier without dashes.
- Enter the 'Cardholder Name' for the person who will be granted access.
- Choose the corresponding 'Plan #' from the drop-down menu.
- Once all fields are filled, review your information for accuracy. Lastly, save your changes and choose to download, print, or send the form directly via fax or email to the Access Card Office.
Complete the Ambulatory Care Center Access Request Form online today to streamline your access request process.
Related links form
A patient access person assists patients in obtaining their medical records and understanding their health information rights. They can guide you through processes like completing the Ambulatory Care Center Access Request Form, ensuring you know what information you can access. Their role is crucial in improving patient engagement and supporting effective communication within the healthcare system.
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