System Access Request Form

Account is: New Change Disable
Systems Needed:
(check all that apply)		 IDX Centricity web access

INFORMATION
Requested Username: Requesting Facility: Requester Email:
Last Name: First Name: MI:
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 your signature)		 Date: