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C o m p u t e r S y s t e m Ac c e s s R e q u e s t F o r m Fax completed Computer System Access Request Form and Confidentiality Agreement to Attn System Access at 231-935-3215 The User or Practice Manager will be notified via email when the request is complete. NOTE Incomplete forms and/or missing information will result in a delay of access. New Employee Change Access or Work Location Employee Legal Name Last Change Name First Termination Middle initial Employee Email Address Employee Social Security Number Employee Gender Female Male Provider NPI Number Credential e*g* MD DO RN Job Title License Number Birthdate MHC Employee ID if applicable Phone / Fax numbers Practice Name Street address of employee s work assignment Clinic Privacy Official Sponsoring Physician required for non-physicians Signature of Immediate Manager Manager Phone Number Manager Email Address Comments Use to indicate secondary work location notes to delete ALL access to computer programs or other information* Applications/Software Dolbey Dictation Listen ID eClinicalWorks Email Access Physician Web Scheduler PWS Practice s Munson-Outlook Schedule all ordering physicians associated with practice listed above. Limit scheduling to ordering physicians listed in Comments. Browse/Inquiry Only PowerChart Read Only Level 1 External no sensitive records Circle requested Position Level NextGen MCIR Clinical nurse manager Medical Assistant Nurse LPN/RN/BSN Other clinical NP/PA Physician Resident Auditor/Compliance Biller Front desk/check out Business Manager Medical Records Practice Manager Billing Student/Intern Med Secretary Student/Intern MA/LPN/RN Student MD/DO/NP PA Student Other Specify Application For questions call the Information Systems Help Desk at 231-935-6053 Revised 10. NOTE Incomplete forms and/or missing information will result in a delay of access. New Employee Change Access or Work Location Employee Legal Name Last Change Name First Termination Middle initial Employee Email Address Employee Social Security Number Employee Gender Female Male Provider NPI Number Credential e*g* MD DO RN Job Title License Number Birthdate MHC Employee ID if applicable Phone / Fax numbers Practice Name Street address of employee s work assignment Clinic Privacy Official Sponsoring Physician required for non-physicians Signature of Immediate Manager Manager Phone Number Manager Email Address Comments Use to indicate secondary work location notes to delete ALL access to computer programs or other information* Applications/Software Dolbey Dictation Listen ID eClinicalWorks Email Access Physician Web Scheduler PWS Practice s Munson-Outlook Schedule all ordering physicians associated with practice listed above. Limit scheduling to ordering physicians listed in Comments. Browse/Inquiry Only PowerChart Read Only Level 1 External no sensitive records Circle requested Position Level NextGen MCIR Clinical nurse manager Medical Assistant Nurse LPN/RN/BSN Other clinical NP/PA Physician Resident Auditor/Compliance Biller Front desk/check out Business Manager Medical Records Practice Manager Billing Student/Intern Med Secretary Student/Intern MA/LPN/RN Student MD/DO/NP PA Student Other Specify Application For questions call the Information Systems Help Desk at 231-935-6053 Revised 10.

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