SECURITY REQUEST FORM
o Original
I.
o Name Change
o Change/Add
o Transfer from dept cost center ________________
OP ID* ______________
Client Information:
Name: * Last___________________________________
*First___________________________________ *MI_______
*Job Title/Position:
*Cost Center: ____________________________ *Department Name:
*10-digit Telephone: ______________________
II.
*Facility: __________________________________
System Information: To be completed by Department Manager.
Routed To and
Completed By
_______
HBOC Series
Group Code*: ______________________
o List facilities by number you are requesting access to: ___________________________________________
_______
_______
_______
Network Connectivity
o LAN account (Local Area Network) Required for E-mail accounts (also known as AD account)
o E-mail
o Remote Access (VPN) – requires CFO Signature
Other Systems
_______
o Destiny, HOD, EOS (Employee to contact Payroll directly for logon and support)
_______
o PACS (Nursing must have signature of CNO, Radiology must have signature of PACS Admin)
_______
o Pyxis
o Med o Supply
_______
o BasWare, Budget, DORS, Trendstar, Vision access. Circle appropriate items and submit to Information
Services.
(For support assistance, please review documentation located on the intranet under Finance Dept).
_______
o Other __________________________________________________________________________________
_______
o Other
Cerner/iConnect requests submitted on Cerner Request Form. See Intranet for Cerner/iConnect Access Forms
*Authorized by: _________________________________________________
Date: _______________
Department Manager Signature
Approved by: ___________________________________
CFO – for Remote & Contractor/Vendor Access
III.
Date: ________________
printed name (if not typed)
Training Information: To be completed by Trainer. (necessary for access to patient care information)
*Trained by: ____________________________________
Trained by Signature
I attest that this individual is competent on the computer systems identified
IV.
__________________________
___________________________Date: __________________
printed name (if not typed)
System Information: To be completed by AHS IS Security
Received: ___________________________________
By/Date
Entered: _________________________________
By/Date
*
Indicates Required Fields – Incomplete forms will be returned to the department
DOB and SSN required for non-employees to obtain OP ID
∞ OP ID is obtained from HR before submitting this form to Information Services
∞ Illegible written signatures, where printed name is not provided by the manager, will be returned to the department
∞ The Security Request Form is an official document that is used to satisfy the JCAHO and HIPAA regulations regarding
computer access of AHS employees. These records are kept in the Information Services Department
∞ Authorized by and Trained by typed signatures are accepted via email from managers, directors or CFO’s
∞ Submit forms to AMHSecurityRequestForm@ahss.org
**
Revised 05/01/09
Security Request Form – FAQ’s
Network Logon -- Also known as Active Directory, AD, or LAN account (Local Area Network)
Uses six digit OP ID or Destiny code
OP ID or Destiny code – Six (6) digit employee code created by Human Resources. The OP ID must be included on the
form before it is submitted to Information Services. Forms submitted to Information Services that do not contain the OP ID
will be returned to the department
OWA – Outlook via the Web
Remote Access
Remote access is not necessary to check email from home or on vacation. Use URL https://ahss.email.org to access OWA.
FAQ’s
1. Why do I need to submit a security request form for computer access?
SRF’s document that your employee has been authorized and trained for specific computer-related duties within your
department.
2. I do not remember what computer access to request on the Security Request Form each time I hire a new employee.
Use a blank form as a template and keep it in your “new hires” file for future reference. If you require assistance in filling
out the template, please call Information Services for assistance. For Cerner security positions, the Cerner Security Positions
List can be found on the Intranet under iConnect Resources.
3. What is a Series Group Code?
The most common Series Group Code is @ORD and is needed for ordering departmental supplies and also needed for the
Series Charge Correction Tool features.
4.
I have an employee that is transferring from X department to my department. Do I need to fill out a new Security
Request Form?
Yes – SRF’s document that you have authorized and trained your employee for specific duties within your department.
Exception -- Transfers between nursing units do not require a new SRF for LAN, Email, or Series ordering. Pyxis MED and
Pyxis Supply access may require a notification to the appropriate Pyxis manager in order to reassign the appropriate cost
center. For Cerner access, complete the Cerner Security Request Form and indicate the appropriate access the employee
needs for your department. The SRF should be completed after the employee is deemed competent in the requested security
position. The competency is not needed when the employee is retaining the same security position.
5.
I have an employee that transferred to another department. The transferred employee no longer needs my
department specific computer access. Who do I notify?
Fill out a security request form and clearly mark at the top that this employee has transferred out of your department. Then
list the computer access that should be removed. This will notify Information Services to coordinate computer access with
another department.
6. How do I notify Information Services of a name change?
Fill out a security request form and clearly mark the old name and the new name on the form. Also identify which computer
systems should be included on the name change. Submissions with “all” will be returned to the department for clarification.
7 How will a name change affect my email address?
The former email address will remain available and the new email address will be added. The new name will appear on the
global address list. Retaining both the former and current email address will assure accurate delivery of email.
8 May I submit a Security Request Form and indicate “same as XXX”?
Security Request Forms are individual for the employee and must clearly state which access has been determined for that
employee. “Same as” forms will be returned to the department.
9 Where do I submit Security Request Forms?
Security Request Forms are submitted via email to AMHSecurityRequestForm@ahss.org
Revised 05/01/09