MULTISYSTEM REQUEST/CHANGE/DELETE FORM
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Today’s Date:
Dept Number:
Effective Date:
Dept Name: Medical Education
Rotation DATES_______________
USER INFORMATION:
ADD X
CHANGE
Date of birth:
DELETE
Position/Title-Requested User: Med'l
Is this a Job2:
PHBaptist:
PHEasley:
8154
Student
PHRichland: X
Direct Report\Supervisor
OTHER:
Margie Bodie
Telephone: 434-4429
Last Name:___
Pager #:
First Name: _________________
Cell #:
Middle Initial:
Login/Name of existing user for a
guide: Kimberly Fisher
Credentials: Medical Student (circle one) 3 4
-
(Please include middle initial &/or employee number.)
Employee #:
SSN: X NON employee ONLY
Emergine
GroupWise:
Distribution List(s):
Additional information, comments:
(list AD shares needed)
BENotification@PHADOM1.corpo
and Easley@BEHDOM1.behcorp
x
Epicenter
FirstNet
Surginet
Scheduling-Surginet
Scheduling-Enterprise
x
Impax
LaserArc
Lawson
CoPath
Sunquest Lab
x
AD
Tier 1 (Groupwise, Mypal)
PFM*
PMM*
QS:
RESQ*
SOLCOM
STAR
x Logician
Full Disclosure
Report2Web
Tier 2 - DIRECTOR APPROVAL
ONLY (Groupwise, MyPal, MSS,
Kronos, PERKS, Position Manager,
Remote Desktop – Must have
dedicated PC - Network File access,
Report2Web, Office 2007)
CMS
VPN
Misys Billing
OTHER:SSO, Citrix Remote
Hospital:
Folder name:
Users, Physician Desktop, citrix
Receiver
MyAccess (Employees Only)
*********************************************************************************************************************************************
Authorized Requestor Information:
Name: Margie Bodie
Title: Administrative Director, Resident & Student Services
Dept Name: Graduate Medical Education
Dept Number: 50-8154
Telephone #: 803-434-4429
Pager#:
-
-
Cell#:
-
-
Authorizing Agent Signature: (if being faxed): _____________________________________________
PRINT Authorizing Agent Name: _________________________________________________________
*SOME APPLICATIONS WILL REQUIRE ADDITIONAL AUTHORIZATION AND/OR FORM*