This form is to be completed for all individuals needing access to Company network/programs.
Once entirely filled out, you must press “SUBMIT”.
"Employee Update / Change" should be selected if an existing employee has changed positions within the same community (i.e. promotion and/or demotion).
"Employee or Third-Party Vision Only Access" should be selected if current employees and/or approved third-party vendors (i.e. Community Medical Directors, Community Pharmacists, Community Therapy) need access to internal specialty programs such as Vision. Be certain to use the IT Request Type of "Resignation / Termination" immediately when our business relationship ends with either.
Certifications or titles that need to be displayed (i.e. DR, RN, LPN, RD, CDM)
Does this user have certifications or titles that need to be displayed next to their name (i.e. DR, RN, LPN, RD, CDM)
Examples include Medical Director, Nurse Practitioner, Pharmacist, Therapist, etc.
Once submitted, an email will be sent (using the user's email address provided above) to the user along with instructions on how to complete the Third Party Appropriate Use Signature Page. The email will come from email@example.com Once the user completes, signs, and returns the form following the instructions, access will be provided directly to the user.
Please remember, if and when our business relationship ends with this individual, be certain to immediately complete the "Resignation / Termination" version of this form to prevent unauthorized access to our system(s).