EHC Account Request

Account Request Information
  Grant New Logon ID
  Change ID Information Only
  Add Access to Existing Logon ID
   Delete Existing Logon ID
 Remove Access to Existing Logon ID

*First Name:    *Last Name:     
      *MI:      *Title/Position:     
*Work Phone:    Professional Lic#:    
*Division:     *Building:     
  Room#:      Floor:      
*Employed By:     *Job Function:     
  Current LOGON ID:    (if you already possess one)

Access Needed:
 User ID  Lotus Notes (E-CC Phone Messaging System)
 Email  Millennium/EeMR/Virtual Desktop

IDX Access (Classroom Training Required):
 IDX Inquirty  Scheduling  Registration  Referrals
 Case Management  Front Desk  Insurance Verif  Charge Entry
 Master Scheduling  Charge Correction  TES  Other 

Additional Information:

 *Requestor:   *Req. Email: 

 

Download, Sign and fax the HIPAA Confidentiality form to 404-712-1322