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450 Stanley Street San Francisco, CA 94117 FAX: 4157508121Exhibit A PATIENTS REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION Date:M.R. # or Account #:Patient Name:AKA/ other names:Date of Birth:
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How to fill out smmc-patient-access-request-01
How to fill out smmc-patient-access-request-01
01
Obtain the SMMC Patient Access Request Form from the designated office or website.
02
Fill out personal information such as name, date of birth, address, and contact information.
03
Provide details about the specific medical record(s) you are requesting access to.
04
Sign and date the form to certify that the information provided is accurate.
05
Submit the completed form to the appropriate party for processing.
Who needs smmc-patient-access-request-01?
01
Patients who want to request access to their own medical records at SMMC.
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What is smmc-patient-access-request-01?
smmc-patient-access-request-01 is a form used to request access to patient information at SMMC.
Who is required to file smmc-patient-access-request-01?
Healthcare providers, employees, or any other individual who needs access to patient information at SMMC.
How to fill out smmc-patient-access-request-01?
To fill out smmc-patient-access-request-01, you need to provide your personal information, reason for access, and sign the consent form.
What is the purpose of smmc-patient-access-request-01?
The purpose of smmc-patient-access-request-01 is to ensure that only authorized individuals can access patient information at SMMC.
What information must be reported on smmc-patient-access-request-01?
On smmc-patient-access-request-01, you must report your name, contact information, reason for access, and signature.
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