Access Request Form

Thank you for your interest in Good Samaritan Hospital’s My.Goodsam.Org Patient Portal. Our web-based patient portal provides our patients with secure and convenient access to their health information. This request form must be completed and submitted for access to My.Goodsam.Org

Personal Information

Mailing Address

A valid email address is required in order to utilize the Patient Portal - My.GoodSam.Org. Please provide a current, personal and private/non-shared email address that only you have access to and verify its accuracy. By providing an email address, you agree to have Good Samaritan Hospital communicate with you regarding via email. Absolutely no protected health information will be included in any email communications from Good Samaritan Hospital.

By checking this box, I acknowledge that I am requesting access to my health information in I understand that access to the patient portal will not expire unless I notify Good Samaritan Hospital in writing to discontinue portal access. understand that the information in my health record.

I hereby afirm that I am the patient identified above. I understand that I may be subject to penalties under law for submitting false or misleading information in connection with this application to access

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