Request Good Samaritan Society Data

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Email a provider through My Sanford Chart.

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Talk with a Sanford nurse over the phone.

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Visit with a provider on a video call for acute care needs 24/7.

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Connect with your doctor on a video call for your clinic appointment.

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Request Good Samaritan Society Data

Please address the following issues:

What is the purpose of your request?*

Please provide information on your purpose of request

Please provide any additional detail of the purpose of your request

What type of entity do you represent?*

Please provide information on your entity type

First Name*

Last Name*

Direct Phone Number*

Email Address*

Organization's Name*

Organization's Website

Organization's Street Address*

Organization's City*

Organization's State*

Organization's Zip Code*

Organization's County

Alias or Previous Name

Title

Provider Specialty

Provider State License Issued

Provider Date Of Birth (MM/DD/YYYY)

Provider NPI Number

Provider License Number

Please select which facility types you are requesting information

Long Term Care(Skilled/Rehab)

Assisted Living

Home Health/Hospice Agency

Services at Home

Please select at least one Facility Type.

Please specify Good Samaritan Society location/s you are requesting information*

Please provide any additional details related to the location/s you are requesting information

In what format do you prefer information to be provided (Select One)?*

Please provide how you would like the information requested delivered to you

Please select the data classes which yor information request includes

This request is for the complete medical record
This request is limited to one or more of the data classes marked below
My information request is not related to the complete medical record nor specific data classes

Please provide expanded details on the population of patients you are requesting information or other details

Allergies & Intolerances

Assessment & Plan of Treatment

Care Team Members

Clinical Notes

Health Concerns

Health Problems

Immunizations

Laboratory

Medications

Patient Demographics

Procedures

Provenance(metadata)

Smoking Status

Unique Device Identifiers for Patient Implantable Devices

Vital Signs

Health Goals

Please select at least one Data Class.

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Please review the information above before submitting your request. By completing and submitting this form, you acknowledge and represent that you are an authorized recipient of the requested information under all applicable state and federal laws.

Coronavirus (COVID-19) Information

Virtual Care Visit

Complete an E-Visit

Call My Sanford Nurse

Do an On-Demand Video Visit

Schedule a Video Visit

Health Information Exchange Request

Request Good Samaritan Society Data

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