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ROI0270.8.006 Exhibit A PATIENTS REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION Date:M.R. # or Account #: Patient Name: AKA / Other Names: Date of Birth:Phone: Address: City/State/Zip: Covering
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01
Gather your personal identification information, including your insurance cards if applicable.
02
Visit the Dignity Health Glendale Memorial website or the hospital in person.
03
Locate the patient registration section on the website or ask for assistance at the registration desk.
04
Fill out the required forms, including personal medical history and contact information.
05
Provide any necessary insurance information, including policy numbers and insurance company details.
06
Review all the information for accuracy before submission.
07
Submit the completed forms either online or at the hospital registration desk.

Who needs dignity health glendale memorial?

01
Individuals requiring medical services or treatment.
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Patients seeking emergency care.
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Those needing specialist consultations or surgeries.
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Residents in the Glendale area needing a hospital with comprehensive healthcare services.
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Dignity Health Glendale Memorial is a hospital located in Glendale, California, providing a range of healthcare services including emergency care, surgical procedures, and other medical treatments.
Health care providers and practitioners who have received services from Dignity Health Glendale Memorial are typically required to file any necessary health records or insurance claims.
To fill out forms related to Dignity Health Glendale Memorial, you should gather all relevant health information, follow the instructions provided on the forms, and submit any required documentation to the hospital.
The purpose of Dignity Health Glendale Memorial is to provide high-quality health care services to the community, ensuring accessible medical treatment and promoting overall health and wellness.
Information that must be reported typically includes patient demographics, medical history, treatments received, and billing information.
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