Santé Web Access Request Form
Print and fax this form to Santé @ (559) 228-2958
Please complete the form in its entirety, and be as accurate as possible.
All Fields are Required.
Who is requesting access to the Santé website.  Please select one of the following:
Provider    Office Manager    Staff
Requester Information  
First Name:
Last Name:
Office Phone:
Requester's Email:
* The requesters user ID and password will be emailed to this account once Santé has set up your online account.
   
Provider or Group Information
Physician Last Name:
Physician First Name:
Group or Institutional Name:
Office Manager:
Address:
Suite Number:
City:
State:
Zip:
Office Phone:
Office Fax Number:
State License Number:
Tax ID Number:
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 _____________

* Office manager signature is not required if a provider is requesting access.


Provider Signature ___________________________________ Date _____________

* Please note that it is your responsibility to notify Santé when an employee no longer works for your
organization to guarantee they no longer have access to your online account and information.