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This form is to be used for new IMPAX account requests, password resets, and account deletions. |
Please provide the following information. All fields are REQUIRED. This form will be returned to you if it is incomplete. Completed requests will be placed in your department inbox in the mailroom. |
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Request Type |
New Change Password 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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Date Needed
Please allow adequate time for account creation. |
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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. |
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E-mail
Where you want the information sent. |
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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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