Follow the steps to successfully fill out the form.

1. Press the ‘Get Form’ button to retrieve the form and open it for editing.
2. Begin by filling in the legal name of the individual requiring access in the designated section. Make sure to print the name clearly.
3. Enter the logon ID if assigned. If not, create a new logon ID in the appropriate field.
4. Fill in the start date for access, and indicate if the individual has been employed with DPHHS before.
5. Specify whether the person is transferring from another DPHHS division, and include any other names that may be applicable.
6. Provide the employer's details, including the work address, work phone, county, and job title.
7. Enter the email address where notifications and accesses will be sent.
8. List the specific access requested under the section provided, indicating the need for view, print, or data entry access.
9. In the justification section, provide a brief explanation of why access is needed.
10. Read and sign the confidentiality and consent statement, affirming the understanding of terms and conditions related to access.
11. The employee must sign and date the form to confirm accuracy and agreement.
12. The supervisor must review the request, sign, and provide their contact information, acknowledging access is granted for six months.
13. If applicable, ensure that the data owner and DPHHS security officer sign and date the form.
14. Once all sections are filled out, review the form for completeness. Save changes and proceed to download, print, or share the completed form as necessary.

Complete your ImMTrax Access Request Form online today to ensure timely processing of your access request.