Office Manager / Staff Request Form
Please complete the form in its entirety.  Please be as accurate as possible.
All Fields are Required.
Provider Information  
Physician Last Name:
Physician First Name:
Group or Institutional Name:
Office Manager:
Address:
Suite Number:
City:
State:
Zip:
Office Phone:
Email:
Fax Number:
State License Number:
Tax ID Number:
Requester Information  
First Name:
Last Name:
Office Phone:
Email:
Comments:
Please include all providers associated with tax id in users online profile.
   
  Privacy Agreement  
I acknowledge that information I view while accessing this system may contain protected health information and confidential
IPA-related information. I agree by signing this form and requesting access that I and my staff will hold any and all patient and IPA-related information in strict confidence and not disclose patient or IPA-related information.

I am aware of my ethical and legal obligation to act in accordance with all Federal and State laws regarding patient confidentiality. I am also aware of my contractual obligation to Santé Community Physicians to act in accordance with my contractual obligation regarding confidential IPA-related information.
 
Office Manager Signature _____________________________ Date _____________

Provider Signature ___________________________________ Date _____________

Print and fax this form to Santé @ (559) 224-2046