Dd form 2962-2026

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The document provides detailed instructions for office staff in the North Florida Division of HCA to complete a Security Access Form. It outlines the steps for requesting access, including filling out required fields, reading and signing a Confidentiality and Security Agreement, and submitting the form via fax or email to specific hospitals. Additionally, it emphasizes the importance of safeguarding patient information and adhering to security protocols, with consequences for violations.

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Click ‘Get Form’ to open the dd form 2962 in the editor.
Begin by filling out the 'Office Staff Requesting Access' section. Ensure all required fields are completed accurately, typing your information directly into each field.
Proceed to the 'Practice Information' section. Enter your practice or company name, address, and contact details as requested.
In the 'Personal Information' section, provide your full name, professional title, home address, email address, and date of birth. Make sure to double-check for accuracy.
Select the type of access you are requesting (New, Change, Reactivation) and specify which medical center you need access to from the provided list.
Review the Confidentiality and Security Agreement carefully. After understanding its terms, print the form and sign where indicated.
Finally, submit your completed form via fax or email to the corresponding hospital using the contact information provided at the end of the document.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (49 Votes)
2018	4.8 Satisfied (60 Votes)

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What is a DD 254 form used for?

Each DISS user will be required to have a DoD approved Public Key Infrastructure (PKI) certificate smartcard/token in the form of a Common Access Card (CAC), Personal Identity Verification (PIV) card, or authorized External Certificate Authority (ECA) certificate.

What are the requirements for diss access?

TO OBTAIN A COPY OF THIS FORM, PLEASE CONTACT THE UNDER SECRETARY OF DEFENSE FOR INTELLIGENCE AND SECURITY (IS).

What is a DD form 2962?

Personnel Security System Access Request Form The PSSAR form, also known as DD Form 2962, is used by the Defense Counterintelligence and Security Agency (DCSA) to collect information required to grant access to personnel security systems, specifically the National Background Investigation Services (NBIS) system.