System Access Request Form

Account is
 
 
 
Systems Needed (check all that apply)
 
 
Requested Username
Requesting Facility
Name
First
Middle
Last
Credentials/Job Title
Set User Up Like (Give username of another user with similar job functionality)
If physician or PA, please provide office phone #

Please note the following information:

* Centricity Web Access will initially be setup with the password “ONETIME”
* IDX will initially be setup with the password that is “SAME AS USER NAME”
* The system will prompt the user to change their password upon their first sign-on
* Passwords must be 6-15 characters

Users of this system must agree to the following:

* All information obtained is strictly confidential and subject to HIPPA regulations
* User accounts are non-transferable, and the user is responsible for all information obtained

User or Manager Signature (typing your name here will substitute for your signature)
Date