Part 2, Chapter 3: Manual Exhibit 2-3-C

On-Line Access Request Form

Instructions: Complete and submit this form to the Project Officer at Indian Health Service (IHS) Headquarters. The form must be signed by the Director, Division of Contract Care (DCC) at Headquarters, and the Area Contract Health Services Officer (CHSO).

Access Request: Access is being requested for the following Contract Health Services staff.

Full Name (last, first, middle initial)	Location	Phone Number & Extension	E-mail Address
______________________	______________________	______________________	______________________
______________________	______________________	______________________	______________________

By Signing below, the Area CHSO verifies that:

A signed confidentiality statement is on file for each employee.
Each employee received Privacy Act training.

This request is submitted by:_______________________________________________________________________________
(Print or type name)

Signature:________________________________________________________________________

Area:___________________________________________________________________________

Date:___________________________________________________________________________

Headquarters action: This request is:

Approved______________
(Send a copy to the Fiscal Intermediary and Area CHSO)

Not Approved___________
(Return copy to Area CHSO)

Approved________________________________________________________________________
(Signature Director, DCC)

Date:____________________________________________________________________________