CERNER SECURITY REQUEST FORM
I.
OP ID* ______________
Client Information:
Type:
o Original
o Add
o Change o Transfer o Name Change
Name: Last___________________________________
First___________________________________ MI_______
Job Title/Position: ________________________________
Cost Center: ____________________________
Credentials: __________ (e.g. RN, COTA; required for Cerner)
Department Name:
10-digit Telephone: ______________________
DOB: ________________________ (required for Cerner)
Home Entity: ___________________________
SSN: ____________________________ (required for Cerner)
Access needed to the following Entities (check all that apply):
o Adventist Bolingbrook
II.
o Adventist Hinsdale
o Adventist GlenOaks o Adventist La Grange Memorial
System Information: To be completed by Department Manager.
Application: ____________________________
Position:___________________________
Toggle Requests: If this user needs access to more than one position, please list any additional position/s here:
_________________________________________________________________________________________
Please indicate if any of the following are required:
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Outreach Organizations
FirstNet Properties
SurgiNet Properties
Scheduling Keys
A list of the available positions is available by selecting the Clinical/Medical section on the Intranet (under iConnect
Resources/Cerner Security Positions List)
III.
Authorization and Training Information: Legible Signatures are REQUIRED for Cerner Access
Authorized by: _________________________________________________
Date: ______________________
Department Manager (print name and then sign)
Approved by: ___________________________________________________
Date: ______________________
CFO – for Remote & Contractor/Vendor Access
Trained by: ___________________________________________________
Date: ______________________
I attest that this individual is competent on the computer systems identified. Please submit last page of completed competency with this form.
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This document is official and provides verification of compliance with state and federal laws governing privacy and
security.
Illegible signatures and incomplete forms will be returned to the department.
Authorized by and Trained by signatures can be typed and then sent via e-mail if sent by the department manager,
department assistant, or the departmental trainer.
For Office Use Only:
Date Request Received: ________________
Received By: ______________________________________
Date Access Initiated/Modified: _____________
Date of Termination from System: ____________________
Send Completed Form to Becky Rossi in Corporate Compliance; Fax: 630.856.4522; Email: Rebecca.Rossi@ahss.org