Harborview Medical Center
Communication Services
Request for Cellular Service
Please return the completed form to the HMC Communication Services Department,
Box 359707 or Fax Number 206-731-2300. Questions? Call 206-731-3440.
PLEASE PRINT LEGIBLY
USER INFO: If the phone is used by a group use group name (e.g. Nurse on call).
Date:
User Name:
Department:
Telephone:
User Signature:
Box Number:
Email:
X
BILLING INFO: To be Completed by Budget Manager:
Cost Center#(to be charged):
Cost Center Name:
Dept Manager Name:
Mgr. Phone:
Box Number:
Budget/Dept Manager Signature:
X
Administrator/Chief Signature:
X
Email:
LOANER PHONES are available to departments for short or limited duration to meet temporary needs.
A minimum of one-month service charge will be billed to the department. Please indicated period of
time needed:
From Date:
To Date:
The department requesting the phone is responsible for the monthly cost of the phone until it
is returned to the Communication Services Department and a receipt is issued. The
department will be responsible for the cost of replacing the phone if it is lost or damaged
beyond repair. If the employee assigned the phone transfers to another department or
leaves HMC, the phone must to be returned to the Communication Services Department for
appropriate billing update.
To be completed by Communication Services Department only:
Phone Number issued:
Phone Model:
Billing Plan:
Date issued:
Phone received by:
Issued by: