INFORMATION TECHNOLOGY

This box is for Access Administration use only
Emp. Status:
Initial
Form 2.2
09/2008
Emailed By:
Ticket #
INFORMATION TECHNOLOGY
Emailed Date:
Access Request Form - HFHS Employees
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IDENTIFICATION: All portions of this section must be filled out completely.
Last Name:
User ID:
First Name:
(New users will be assigned one)
Middle Initial:
Social Security -or- Employee Number:
Male
Work Phone:
Job Title:
Female
or Ext:
Cost Center:
Location (building):
Floor/Room #:
Will this person ever rotate through the Main Campus ER?
Department:
Current Employee
New Hire
Recent Transfer
YES
Transfer from & date:
Manager's Name:
System & Application Access
CarePlus (complete CarePlus section found on next page)
Novell Netware ID
ExcelCare
E-mail Account (Additional information may be added on next page)
Citrix What Citrix applications will you be accessing?:
CORP
MisysLab
Portal
Kronos
MisysCoPath
assigned by Pathology Informatics
AS400 (enter model)
Metavision (choose role & ICU)
Metavision ICU
Role
UNIX Please Specify:
HFHS/HFMG Business Units:
MPAC
BCBS
T-System
Appt. Sched. (View only)
PEMS
Trans Cap
BI-WEB
Appt. Sched. (ASMD)
TSO
HFHS BAM
PANS
Corp. Billing (enter model)
Time Entry
Order Entry
Cost center(s) for which time will be entered:
Claims Admin (CA):
(CA) HFH
(CA) HFMG
(CA) Kingswood
Warren Campus specific applications:
BCBS-Blue Cross
TSO-ISP/PDF
OAM/E
Invision (enter model)
Other Access (specify):
Beta93-Report Dist. (enter model)
(CA) Dashboard
Departmental Order Entry
NO
Additional information required for Careplus access
Date of Birth:
Business Unit:
HFH
Wyandotte
Warren Campus
West Bloomfield
Other (specify below)
Other hospital(s):
What is your professional designator (Ph.D, MSW, CRNA, etc):
What is your Appointment Scheduling Doctor Code (dictation code):
Physicians, Residents and Fellows:
At what hospital(s) do you currently have admitting privileges?
HFH
Wyandotte
Warren Campus
West Bloomfield
Other (specify below)
Other hospital(s):
Additional Novell Information
User's access needs to be modeled after (supply name below):
Enter model:
Network share access (in addition to home drive and if known):
Separate entries
with a comma.
Additional Email Information
Additional e-mail distribution list(s) to which the user should be added (if known):
Separate entries
with a comma.
Active Directory (CORP) groups to be added
AD/CORP
Groups
(if known)
Additional notes/requests/comments
Notes:
This form is for HFHS Employees only, All contractor, temp, student or agency employees must use contractor form IS220
Please contact Access Administration at (248) 853-4950 if you have any questions.
Manager or authorized submitter may either press "submit via Email" button or save form and email to [email protected]
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