Network/Email Account Request Form

Enterprise EMR Account Request Form

____________________________________________________________________________

* Account Type: Enterprise EMR Account

* First Name:

Middle Initial:

* Last Name:

* DEA Number

* State License

* DPS Number

* Location/Department:

* Title:

* Work Address:

Work Phone Number:

Fax Number:

* Office Manager Name:

*Enterprise Discipline :

(i.e. Physician, Resident, Nurse, etc.)

Enterprise Dictation:

(i.e. Physician, Resident, etc.)

Attending Physician(s): (List their names if your dictations require an attending's signature.)

Touch Chart (Scan):

(i.e. Nurse, MA, Front Desk, etc.)

(The secret question is used by the help desk staff to insure they know they are talking to the correct person. Without this security question, it my not be possible to change or reset your password. Please choose a question and answer that only you would probably know.)

Secret Question:

Secret Answer:

Additional Notes/Comments:

Enterprise access usernames and passwords are assigned to and are the responsibility of the User. This information is NOT to be shared among other personnel. An Enterprise Analyst will delete/deactivate the Enterprise User Account of anyone found to be violating this policy. The Enterprise User Account will be deactivated immediately upon verification of the information. An Enterprise Analyst will notify the department Security Contact that the user has been deleted/deactivated.

* First Name:
Middle Initial:
* Last Name:
* DEA Number
* State License
* DPS Number
* Location/Department:
* Title:
* Work Address:
Work Phone Number:
Fax Number:
* Office Manager Name:

*Enterprise Discipline :	(i.e. Physician, Resident, Nurse, etc.)
Enterprise Dictation:	(i.e. Physician, Resident, etc.)
Attending Physician(s):	(List their names if your dictations require an attending's signature.)
Touch Chart (Scan):	(i.e. Nurse, MA, Front Desk, etc.)

Secret Question:
Secret Answer:
Additional Notes/Comments:
Enterprise access usernames and passwords are assigned to and are the responsibility of the User. This information is NOT to be shared among other personnel. An Enterprise Analyst will delete/deactivate the Enterprise User Account of anyone found to be violating this policy. The Enterprise User Account will be deactivated immediately upon verification of the information. An Enterprise Analyst will notify the department Security Contact that the user has been deleted/deactivated.