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Remote Access Request
This form is to be used for new remote access account requests and remote access account deletions.
Please provide the following information. All fields are REQUIRED. This form will be returned to you if it is incomplete.
*	Request Type	New     Change Password     Delete Account
*	Date MM/DD/YYYY
*	Phone Number
*	First Name
*	Last Name
*	Date Needed Please allow adequate time for account creation.
*	Department
*	Access Needed	CPSI E-MAIL Active Sync OWA IMPAX VPN
*	Job Title
*	Badge Number
*	E-mail
*	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
*	Reason For Request