Computer Access Form Print Clearly - Fax Completed form to 9, 321- 6199 - Allow 72 Hours for Processing Badge # ____________________________ New Request Date of Request Additional Request Change Request Legal First Name Ml Legal Last Name Facility/Location Title Department Contact Number Password (For temporary password, please contact Support Security Questions Services at x5555) Mother's Maiden Name City of Birth CHANGE REQUEST Legal First Name Ml Legal Last Name New Facility/Location New Title New Department Permanent New Phone Number Temporary - if temp, enter end date / / (if no end date, ID will expire in 90 days) (MM / DD / YYYY) Employee Signature Employee Signature (print) Department Supervisor Signature Department Supervisor Signature (print) Department Supervisor Phone Authorized Trainer Signature Validated by Network ID IST SSA II Signature Date Created Username: Name: Create Like: Remote Referring Office Staff Valleylink Financials DESCRIPTION Business Office ValleyLink Clinicals DESCRIPTION Audiologist AUD Cash Posting CRC Analyst CRC Business Office CRC Supervisor Service Catalog User Financial Counselor General Ancillary General Charge Ancillary BCH CNA Certified Nursing Assistant BCH General Access BCH IC Infection Control BCH LPN Licensed Practical Nurse BCH OT Occupational Therapist BCH Pharmacy BCH Physician BCH Physician CPOE BCH PT Physical Therapist BCH CNA BCH General BCH IC BCH LPN BCH OT BCH Pharmacy BCH Physician BCH Physician CPOE BCH PT BCH PTA Physical Therapist Assistant BCH PTA BCH Rd Registered Dietician BCH RN Registered Nurse BCH RT Respiratory Therapist BCH ST Speech Therapist Child Life Specialist/TR Specialist Certified Nursing Assistant Coordination of Care General Access Heart Center Infection Control Licensed Practical Nurse Recreational Therapist LTAC Physician Neuropsychologist Occupational Therapist Pharmacy Physician Physical Therapist Physical Therapist Assistant Radiologic Technologist Registered Dietician Registered Nurse Respiratory Risk Assessment Entry Respiratory Therapist Sleep Lab Speech Therapist Support Services VID Billing VID Physicians View Only VMA APOGEE VMA Billing BCH RD BCH RN BCH RT BCH ST CLS CNA COC General Heart Center IC LPN LRT/CTRS LTAC Physician NPsy OT Pharmacy Physician PT PTA Rad Tech RD RN RRA RT Sleep Lab ST Support services VID Billing VID Physicians VIEW VMA APOGEE VMA Billing VMA Physicians VMA Physicians Lab Quick Registration Registration Supervisor HIM Administrator HIM Analyst HIM Charge Analyst HIM Code Abstractor HIM Data Revision Analyst HIM Supervisor HIM Vital Statistics Analyst Information Desk/VolSe Performance Improvement Coordination of Care IST Analyst Master User LEVEL Username: Name: Create Like: Remote Referring Office Staff Invision Patient Financials DI Cash APPS DI Cash Scan DI COC DI ED Clerk DI PA Clerk DI Passport DI PBO DI PFS Reports DI PMREG DI RNAUDIT DI Supervisors SSI Softmed Level Admit Supervisor 1Asign03 Anc—CFVMC GANCSO01 Anes/Pain MGT 1ASIGN01 Budget/Reimb 1ASING07 Case Management 1USIGN02 Infection Control 1QSIGN01 Information Desk 1ISIGN01 Marketing (CH) MKSIGN02 Neurodiagnostics License Practical Nurse INSIGN01 1NNSSO02 Nursing Assistant 1NNSSO03 Registered Nurse 1NNSSO01 Nursing Admin 2NNSSO01 RN Student 1NNSSO04 DI_HIM Codes Nursing - CH CHSIGN01 DI_HIM Analyst CF Patient Accounting CWSIGN05 Patient Financial Services PASING10 Patient Financial Service Gold Health Information DI_HIM Analyst HR DI_HIM Internal Review Patient Relations Quality Assurance CWSIGN20 PRSIGN01 1QSIGN01 DI_HIM Scan and Other Registrar 1ASIGN02 DI_HIM Expanded View Risk Management 1QSIGN01 Social Work/UM 1USIGN01 DI_HIM Printers HIM Admin CF 1MSIGN12 DI_HIM Coders HIM Admin CH 3MSIGN12 DI_HIM Supervisors HIM Birth Cert 2MSING22 HIM Data Entry 1MSIGN22 HIM Supervisor 2MSIGN13 HIM Techs 1MSIGN11 Coder/Abstractor 2MSIGN12 Transcriptions PMSIGN01 Volunteers Hospital Vital Stats 1VISIGN01 DI_HIM Clinician Compl DI_HIM Admins CERNER EMR Pathnet PPID/HHSC Surginet Other Atstaff AeroScout Catalyst CSI Department Drive Dephinitive Access DSS DSS Web Publishing Emstat IMPAC Lawson MAK Medinformatrix Nurse Portal iECG OBTV Office Max Order Facilitator PcCharge PTEX RapidComm RMS SAMM Smartworks Syngo Workflow Syngo Imaging IntelliSpace Portal Teletracking Scheduling-Scheduler Scheduling-View Print FormFast Bladen AUNA AUNB CCOU CICU CSIC CSOR CVSU CVRU CCOU CVOU EDBZ EDGZ EDRZ EDYZ EDPK FCCN FCCU HICU H3FL F4FL H4FL INTU LDRU MICU NEPH NICU OBSA OBRR OBSB PACU PICU REBI RGEN RSCI SICU SSUN 1ADU AYSU 1RAC 2SOU 3GYn 3SOU 4SOU SNOR 5SOU 6SOU 7SOU 8SOU 3VPS 3VPN 4VPS PSUR Supp Staff
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