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Information Systems Access Request |
Please select which applications and systems your user needs access to: Network access, email access, Azalea Health, CPSI, CPSI ChartLink |
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Request Type |
New Add Security Remove Security Department Transfer Contractor Student Change Name Delete Account |
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Date
MM/DD/YYYY |
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Phone Number |
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First Name |
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Middle Name |
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Last Name |
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Email
Email address of user access is being requested for. |
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Date Needed
Please allow adequate time for account creation. ASAP is not a date. |
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Dept/Practice |
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Job Title
Job Title of employee |
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Badge Number
Badge number of employee or physician needing access. (Account will not be created without this information) Not required for office staff. |
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Employee Mirror
Badge number of another employee with same job duties. |
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E-mail
E-mail of person submitting request |
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Applications |
Network Access
Email Access
CPSI
American HealthTech
LRMC Remote Access
T-Systems
TraceMasterVue
Azalea Health
Perinatal Centricity
Dragon
Athena Practice
Phillips Intellispace
E-Scribe
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CPSI Applications |
Accounts Payable
Admissions
Billing/Accounts Receivable
ChartLink
Point of Care
Fixed Assets
General Ledger Accounting Reports
Lab
Materials Management Requisitioning
Notes
CPSIQ
Ad Hoc
Quality Reporting
Web Client
Communication Center
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Additional Requests
This is to be used for any other user needs. (e.g. access to secured folder shares.) |
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Confidentiality Agreement
Confidentiality Agreement: I agree: (1) Only to use confidential information to provide services or goods to Liberty Regional Medical Center, (2) Only to communicate confidential information to physicians, staff, and contractors on a need-to-know basis, and (3) Not otherwise disclose or use at any time any confidential information which includes, but is not limited to, discussion of pay rates, access codes, patient information, etc. Authorized users only. Use of this system may be monitored and recorded by systems personnel. Users expressly consent to such monitoring and are advised that suspected criminal activity will be reported to law enforcement. |
Agree Disagree |
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