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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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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:

  1. A signed confidentiality statement is on file for each employee.

  2. 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 Copy to the Fiscal Intermediary and Area CHSO)
Not Approved _______________
(Return a copy to the Area CHSO)
Approved ________________________________________________________________________
(Signature Director, DCC)
Date ________________________________________________________________________



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