Incident #:
Work Order #:
PITCName:

INFORMATION TECHNOLOGY DEPARTMENT

PHYSICIAN/ALLIED HEALTH PROFESSIONAL APPLICATION ACCESS FORM

All information MUST be typed or printed in all fields.Information about person for whom application is being requested:

First and Last Name
(Please include middle initial) / Provider ID or #
Title / Specialty
Address / Phone
Email / Cell
Practice Name / AD User Name
Office Manager / BHSF Employee / Yes / No
Physician Group Members:
(Required for accurate group census)
(Attach separate sheet if necessary)

Please check all Baptist Health South Florida facilities where you have privileges:

Hospitals: / Urgent Care Centers:
Baptist Hospital / BHC - BAP HLTH CTR URG CAR / WST - WESTON UC - WST
Baptist Outpatient Services / BUC - BRICKELL URG CARE / CWU - COUNTRY WALK UC
Doctors Hospital / CSU - CORAL SPRINGS UC-CSU / PBU - PALMETTO BAY UC-PBU
Homestead Hospital / DAU - DAVIE UC - DAU / KLU - KENDALE LAKES UC-KLU
Mariners Hospital / DUC - DORAL URG CARE-DUC / KWU - WEST KENDALL URG-KWU
MASC BHM / GDU - CORAL GABLES UC-GDU / PIN - PINECREST UC-PIN
MASC SMH / MLU - MIAMI LAKES UC-MLU / TUC - TAMIAMI URG CARE-TUC
South Miami Hospital / PPU - PEMB PINES UC-PPU / WUC - WESTCHESTER URG -WUC
West Kendall Baptist Hospital / UUC - UNIVERSITY UC-UUC
Please check if you are a New User or would like to Revise access

Please check all the applications where access is needed:

Internet(For access to the Internet) / Dashboard(For access to applications remotely)
T-Systems(For access to ED clinical documentation)
Must fill out T-Systems Security Form. / Syngo-Radiology(Radiology dept. use and/or readership purposes) (Please check only one)
Anesthesiologist Cardiovascular Radiologist
AD - Network Login (For access to BHSF computers) / PACS(For access to Picture Archive Communication System) (Please check only one)
Radiologist BCVI Physician ED Physician
ICU Physician NICU Physician Referring Physician
EssentrisBHM HH SMH WKBH
Sovera(For access to Medical Records) / Baptist AnesthesiaPyxis
Anesthesia Endo IVR-A LDR MRI
Net Access(For access to clinical patient information)
(A member of your office staff (1) per physician may also have NetAccess) / Baptist Pyxis MedstationBHM SMH
Anesthesia
Incident #:
Work Order #:
PITCName:

Please check all the applications where access is needed: (continued)

Ovation Pleaseselect one:Baptist Author Baptist Review Only Author / KinetDx / WebPro
NeoData
Addition / Modification
NOTE TO BA: User will need to be added to the AG-NeoData4-SM / AG-NeoData4-BH groups.
Modification (if applicable):
Unit Authorization: / BHM / SMH
Job Class: / SDN-B / SDN-ARNP / CCNS
CCNS-ARNP / VIEW/PRINT / SUPERUSER
SDN/CCNS
Does their name have to be added to the Preparer drop down list? / Yes / No
Does their name have to be added to the Attending MD drop down list? / Yes / No
Wireless Network Access / Application Type: / Administrative / Clinical
Device Type:
Remote Applications Needed:
BHSF Citrix Remote Access / Token #
Remote Applications Needed:

By signing below you have read and agreed to BHSF Policy 105 in your package.

Signature / Date

You are requesting a password and user ID to the Document Management System (“DMS”). The DMS contains confidential patient information. Confidential patient information may only be retrieved and viewed by physicians, nurses and hospital personnel who are authorized to access such information. In order to maintain patient confidentiality, it is extremely important that you rigorously safeguard your password. You are the only person authorized to use the password assigned to you, therefore, you will be held accountable if someone else uses it. DO NOT GIVE YOUR PASSWORD TO ANYONE; this includes colleagues, nursing personnel, hospital personnel, office staff and everyone other than you.

An audit trail is created every time your password is used to access the system and the audit trail is reviewed on a regular basis. UNAUTHORIZED USE OF DMS PASSWORDS AND USE OF ANOTHER AUTHORIZED USERS PASSWORD IS STRICTLY PROHIBITED AND MAY SUBJECT YOU TO DISCIPLINARY ACTION INCLUDING BUT NOT LIMITED TO LOSS OF MEDICAL STAFF PRIVILEGES. I have read and understand the above and agree to be bound by same.

Signature / Date

Please return completed form with application to Medical Staff Office. A representative from the PITC team will contact you with training dates and times shortly after credentialing process has been completed.

*** Net Access and Dashboard are for PC ONLY. MAC is not supported. Ver4.9-.786.533.9931-TERMMB-07.03.2012-SEC

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