The SHMS-7807 form plays a crucial role in the process of gaining access to MySwedes Chart, a user-friendly, web-based patient portal offered by SwedishAmerican Health System, a division of UW Health. This portal empowers patients by providing them secure and convenient access to their health information online. To access the services of MySwedes Chart, individuals must complete and submit the SHMS-7807 form, which necessitates providing personal information such as full legal name, the last four digits of their Social Security number, date of birth, mailing address, and a valid email address. It's important to note that this form requires in-person submission to ensure the protection of patient identity. The form also outlines the necessity of a valid email address for utilizing MySwedes Chart, underscoring that while email communications will be used for portal-related communication, no protected health information will be shared via email. Moreover, the form includes sections for office use, specifying procedures for SwedishAmerican Health System employees who assist patients with their access requests. This includes verifying the patient's identity and ensuring the form is properly completed and submitted, demonstrating the thorough process in place to safeguard patient information and access to this digital health resource.
| Question | Answer |
|---|---|
| Form Name | Form Shms 7807 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | myswedes, myswedeschart, myswedeschart login, MySwedes |
Request for Access
Thank you for your interest in SwedishAmerican’s MySwedes Chart, an
Instructions
Please complete the “Your Information” section of the request form and sign where indicated below.
Your Information: (Please print clearly.)
Full Legal Name_________________________________________________________________________
Last NameFirst NameMiddle Initial
Social Security Number (last 4 digits)
Mailing Address: ____________________________ City: _________________ State: _____ Zip: ________
*Email Address: _______________________________________ Phone Number: ____________________
*A valid email address is required in order to utilize MySwedes Chart. Please provide a current private email address and verify accuracy. By providing an email address, you agree to have SwedishAmerican communicate with you regarding MySwedes Chart via email. Absolutely no protected health information will be included in any email communications from SwedishAmerican Health System – A Division of UW Health.
By signing below, I acknowledge that I am requesting access to my health information in MySwedes Chart.
_____________________________________________________________ |
___________________ |
Signature of Patient |
Date |
For Office Use Only
To SAHS employees assisting patients with access requests to MySwedes Chart, please complete the following:
Location where request was initiated: |
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□ SAMG Clinic Name ___________________________ □ SAH Unit ______________ |
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Applicable EMR Medical Record Number: |
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□Epic □ Meditech |
MRN _________________________________ |
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Indicate type of Photo ID verified: |
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□ Other _________________________ |
□ Drivers License/State ID □ Government ID □ Passport |
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□Indicate that you have verified completion of the Request for MySwedes Chart Form by the patient.
Employee Printed Name _____________________________________________________________ Code Generated Yes
Employee Signature ______________________________________________________________ Date ___/____/___ Time______
(For SAH and
Request for Access to MySwedes Chart Form