Please complete highlighted areas
Fax completed form back to Pharmacy Department
Attention Michael Leifheit
419 423 5167
Or mail copy to
Blanchard Valley Hospital
Attention Michael Leifheit Pharmacy Department
1900 South Main Street
Findlay Ohio 45840
BLANCHARD VALLEY HEALTH SYSTEM
SYSTEM ACCESS APPLICATION
Section One - ASSOCIATE: Please print the following information clearly and completely (as applicable) being sure
numbers and letters are legible. Read and sign the statement below.
Please Select: □ New User
□ Name Change
First Name
□ Reactivate
Middle Initial
□ Transfer
□ Menu Change for Job Title
Last Name (if name change, include previous last name)
Job Title
Department - Nursing Unit (if applicable)
Electronic Signature PIN (4 numbers):
//////////////////////////
(signing providers only – does not expire)
If I feel that my access has become known to others, it is my responsibility to inform my supervisor and request password(s) reset.
Signature:
Date:
Section Two - MANAGER/DIRECTOR: Please check the following access options as needed by the associate.
□ NETWORK ACCESS ONLY
□ ACUDOSE
□ KRONOS
□ ENDOWORKS
□ CYBERVIEW
□ FORMIMPRINT
□ MEDITECH
□ If in multiple departments, list main dept.: __________________________
□ If transfer, previous dept. access still needed. List previous dept(s): ___________________________
Is the previous dept. access temporary or permanent?(if temporary, please provide expiration date) _________________
□ Able to view confidential data (Results, etc. for non-confidential patients)
Associate menu will be the same as: Michael Leifheit______________(enter name of associate with same access needed).
If access requested does not match job title, IT will contact manager/director before access is granted.
□ AOD (circle a user group and create a password)
SS
(Social Services)
ACT
(Activities)
DIET
(Dietary)
ACCT STAFF
(Billing & AP Data Entry)
ACCTG
(Accounting)
CHAP
(Chaplain)
CNM
(Clinical Nurse Manager)
NURSE
(nurse)
NOTES (please print legibly):____MEDITECH ACCESS ONLY______________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Manager/Director/Instructor/HR Rep Name: (please print)___________________________________
Manager/Director/Instructor/HR Rep Signature: _________________________________________
Course of Study (LPN, RN, etc.): _Pharmacy
School: __Ohio Northern
Instructor’s Name: _Michael Leifheit___________
Instructor’s Email Address: ___mleifheit@bvhealthsystem.org________
(for notification purposes)
Meditech Password (2 letters & 4 numbers, any order):
_____________________
End date (access will be inactivated on this date): ________________
FOR I.T. USE ONLY:
STUDENTS: please clearly print the following information
AD ID: _________________
MG Live ___ Test ___
AD pswd: _______________
CS Unv __ Live __ Test __
Email account: Yes or No
AD init/date: _____________
CS pswd ______________
NUR ___ MSM ___
Acudose ____ BMV ____
MT ID: _________________
Spooling ____________
MT pswd: _______________
OPS code ___________
MT init/date: _____________ Long Dist PIN: _______
Valco __________
**PLEASE FAX COMPLETED FORM TO 419-423-5363**
Form ADM 10 (DLS 3/98)
SYSTEM ACCESS FORM INSTRUCTIONS
*** It may take up to 5 business days to complete a request ***
Section One – ASSOCIATE
Please print all information clearly and completely or processing could be delayed.
1. Select whether this request is for a new user, name change, reactivation, transfer, or menu change for Job Title.
 Menu changes are made for Job Titles, not for individual users. The manager/director only needs to fill
out the Job Title and Department fields in the “Associate” section, write the changes needed in the
“Notes” field in the “Manager/Director” section, and print and sign his/her name.
2. Enter the associate’s First Name, Middle Initial, Last Name, Job Title, and Department.
 If this is a name change, please enter the new last name followed by the old last name in parenthesis.
 The Electronic Signature PIN is only for providers that will electronically sign documents.
3. Associate should sign and date the request if they agree with the statement.
Section Two – MANAGER/DIRECTOR
Please print all information clearly and completely or processing could be delayed.
1. Select whether the associate needs Network Access Only or needs access to one or more of the following
applications:
 Admin Rx/Acudose – used by Nursing and Pharmacy for Med administration and dispensing
 Kronos – timekeeper software mainly needed for associates who do not have access to a time clock and
managers who need to approve time cards and/or schedules
 Endoworks – Endoscopy Data Management software used mainly in CDS2, ICU, ER, and Surgery
 Cyberview – software for managers/directors to view Meditech data
 FormImprint - software used to print medical record forms with merged patient data
2. Select whether the associate needs MEDITECH access.
 Select the facilities in which the associate will be working and/or needs to access patient information.
 If the associate works in multiple departments, list the main department.
 If this is a transfer request and access is still needed for the previous department, please list the previous
deparment. Also, please identify if the previous department access is permanent or temporary and
provide an end date if temporary.
 Select if the associate needs access to view patients designated as “confidential” (this includes patients
on Orchard Hall). The Psych Manager’s signature is required for this access (currently this is Dianne
Resseguie on Orchard Hall).
 Select if the associate needs access to view confidential data. This information includes results of
confidential tests (such as the HIV test) done on non-confidential patients.
 Enter the name of a current associate with the same access needed for the new associate.
3. Select whether the associate needs AOD access (this system is used at the Birchaven location).
 Choose which of the following access groups: Activities, Dietary, Billing & AP Data Entry, Nurse, Social
Services, Accounting, Chaplain, Clinical Nurse Manager, or Other.
 Have the associate enter a permanent password. It is case-sensitive and must be 6-8 characters
including one number.
4. NOTES: Enter any additional information on the lines provided (such as details for a menu change request).
5. The Manager/Director/Instructor/HR Representative must print his/her name.
6. The Manager/Director/Instructor/HR Representative must sign his/her name to approve the request.
** UPON COMPLETION, the Manager/Director/Instructor will be notified via email with the username(s) and
password(s) unless otherwise noted on the form. If this is a name change, reactivation, transfer, or menu change, the
associate will also receive notification via email.
Section Three – STUDENTS
Please print all information clearly and completely or processing could be delayed.
1. Along with filling out the ASSOCIATE and MANGER/DIRECTOR section, students must also fill out this bottom
section.
2. Enter the course of study and the school you are attending.
3. Please print the Instructor’s name and email address for notification purposes.
4. The student must enter a permanent password consisting of 2 letters and 4 numbers in any order.
5. Enter the End Date, or last day in which the student will need access to the system. This date should reflect the
last clinical date of the grading period. A new password sheet will need to be filled out for each grading period.