Get System Request Form

Filling out the System Request Form online can be a straightforward process if you follow each step carefully. This guide is designed to help you navigate through the form’s various sections and fields effectively.

Follow the steps to complete your System Request Form.

1. Click the ‘Get Form’ button to obtain the form and access it in the editor.
2. Indicate the type of request you are making by selecting either 'New Employee,' 'Change Access or Work Location,' or 'Termination.' Make sure to check all applicable boxes.
3. Fill in the employee legal name fields: Last, First, and Middle initial. This information should reflect the name on official documentation.
4. Enter the employee email address, social security number, birthdate, and MHC employee ID if applicable. Ensure that all information is accurate to avoid delays.
5. Specify the job title, provider NPI number, license number, and contact numbers. Providing complete details helps in processing the request efficiently.
6. Indicate the practice name and the street address of the employee’s work establishment.
7. Include information regarding the clinic privacy official and the sponsoring physician if applicable. This is a requirement for non-physicians.
8. The immediate manager must sign the form and provide their phone number and email address. This validates the request.
9. Use the comments section to indicate any additional information, such as a secondary work location or instructions to delete access.
10. Select the necessary applications or software that the individual will require access to, ensuring to circle the requested position level.
11. Review the form for completeness, making sure all fields are filled out correctly to avoid delays.
12. Upon finalizing the form, you can save changes, download, print, or share the completed document as needed.

Prepare and submit your System Request Form online to ensure complete and timely access.