STEWARDHEALTHCAREINFORMATION SYSTEMS ACCESS REQUEST

START DATE: ______END DATE: ______(required– estimate if unknown. If blank, will assume 6 mo from start date)

Action Requested (choose all action(s)that apply and choose sub-action where appropriate)

Add Employee: □Full time Employee□Part time Employee □PRN

Add Contractor:□ Workforce X Non-Employed Physician/Staff□ Third Party Vendor

Cerner Provisioning Required.

Chg EE Status: □ Full time Employee □ Part time Employee □ PRN

Chg Contractor Status: □ Workforce □ Non-Employed Physician/Staff □ Third Party Vendor

Add/Remove Services(indicate services added/remove below)

Name or Dept. Change (Prior Name: ______Prior Dept: ______)

Termination (all access will be disabled)

Incomplete forms are not accepted. For guidance, refer to SEC.007.1: User Access Managementon I-REPP*REQUIRED FIELDS

*First Name

/ *MI / *Last Name / *Contact No.: Area Code/Number/Ext.
*Job Title: / Employee/Contract ID(if unknown, full SSN)
*Department Name: / *Facility Location or Name of External Company:
Financial Applications
/ □ GHX Connect Plus / □ Transcription
Lawson Financials / □ Document Express: / □ Blood Bank
□ CFO / □ Other: / □ Medhost
□ Controller /
Clinical / Patient Accounting Apps
/ □ ePremis (STAR)
□ Asst. Controller/Sr. Accountant / McKesson Applications / □ ePremis (Edge Cerner)
□ Accountant / □ Radiology / □ ACM Claims Scrubber
□ Accounts Payable / □ Laboratory / X Cerner
□ GL Inquiry / □ Patient Care / Order Entry / □Cerner Edge CPA(Cerner Patient Accounting)
Lawson Procurement / □ Pharmacy / □Edge Position Name:
□ Buyer / □ Patient Accounting / Other Applications/Connections
□ Receiver / □ Patient Accounting w/ Refunds / XCitrix
□ Issuer / □ Compliance Advisor / □ Reveal
□ Materials Management (all) / □ Scheduling / □ Microsoft Office: □ All □ Viewers
□ Requisition Self Service (RSS) / □ Surgical Manager / □ Departmental Directories
□ Web Requisitions / □ Clinical Browser/Portal / □ Lotus Notes
Lawson Payroll / □ Patient Folders / □ OneStream Analyzer
□ Payroll / □ Horizon Clinical / □ Bi-Portal
□ Human Resources / □ Patient Processing / □VPN
□ Oracle DB (must be approved by CIO) / □ Contract Management (PCON) / □Internet
Other Financials / □ NextGen EMR / □ Nurse Scheduling:
□ API / Other Clinical / Patient Accounting / □OnBase
□ BCX -- ScanReq / □ Quantim / □ Other:

By signing below, I attest that the user listed on this access request form has the business need for access to above requested systems. Once signed, send to HR. Note: If user is Third Party, I also attest that I have verified the existence of an active contract and Business Associate Agreement (if PHI is involved) between Steward and Third Party Company. Send Third Party Access Form and signed Confidentiality & Security Agreement (CSA) directly to IS.

*Department Mgr/Director/Third Party SponsorSignature: *Date:

*Printed Name of Requestor (Office Staff Member):

By signing below, I attest that the employee listed on this request form has signed a CSA and the Job Title is correct.

*Human Resource Representative Signature: *Date:

*Chief Privacy Information Security Officer: *Date:

This page must be completed by Steward Information Systems Administrators

The administrator must state action taken, sign this formreturn a completed copy to HR,

or applicable Steward Third Party Sponsor

If user is an agency nurse, check list of approved agencies. Agency is listed, *circle one: (yes) or (no)

*User ID Assigned:(If New User Account)

*Action taken & Application(s) affected:

*Admin (print):

*Admin (sign): *Date Complete:

*User ID Assigned: (If New User Account)

*Action taken & Application(s) affected:

*Admin (print):

*Admin (sign): *Date Complete:

*User ID Assigned: (If New User Account)

*Action taken & Application(s) affected:

*Admin (print):

*Admin (sign): *Date Complete:

*User ID Assigned: (If New User Account)

*Action taken & Application(s) affected:

*Admin (print):

*Admin (sign): *Date Complete:

Version 5.6

Last Updated 7.1.20171 of 2