Form Shms 7807 – Fill Out and Use This PDF

Request for Access

Thank you for your interest in SwedishAmerican’s MySwedes Chart, an easy-to-use Web-based patient portal that provides you with secure and convenient access to your health information. This request form must be completed to apply for access to MySwedes Chart. This form must be presented in person to protect patient identity.

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) XXX-XX-___________ Date of Birth: __________________________

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:
□ SAMG Clinic Name ___________________________ □ SAH Unit ______________ □SAMC-B Unit _________ □ HIMS
Applicable EMR Medical Record Number:
□Epic □ Meditech	MRN _________________________________
Indicate type of Photo ID verified:		□ Other _________________________
□ Drivers License/State ID □ Government ID □ Passport

□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 SAMC-B employees only, fax to HIMS 815-964-3383)

Request for Access to MySwedes Chart Form

SHMS-7807 02/26/15