	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:

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