USA Help - Access Form

IT Support Desk

Access Form	Required fields designated by: \|

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Your First Name:	\|	Your Email Address:	\|
Your Last Name:	\|	Your Office Phone:	\|
Your Windows Username:	\|	Your Mobile Phone:
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Employee	Provider	Contractor/Vendor
Please make sure you have a Business Associate Agreement (BAA) on file
If this provider needs access to Cerner and/or PACS they would have to be privileged as a community provider at minimum through the Medical Staff Office. Please work through them to get the physician the access they need: medstaffcredentials@health.southalabama.edu. Common provider titles are CW Clinical Psychologist, CW Speech Language Pathologist, CW Respiratory Therapist, Clinical Pharmacist, NGRNP, Nursing Instructor, MD, MA, CRNP and occasional RN's. If you are not submitting for one of these titles, please use the Employee radial button to request an account.

Submitter Location: | Bulk Request?

Action Requested: \|	Full Name: \|	Effective Date: \|	Termination Date: \|
Note: Select Transfer if User is changing departments		Kloud 7 User?
WARNING! You are requesting to remove/terminate access for a USA Health provider. Only the USA Health Medical Staff Office can request this action to ensure compliance with the by-laws governing the medical staff. This ticket will not be submitted at this time. Please contact the Medical Staff Office with any questions by emailing medstaffcredentials@health.southalabama.edu or calling (251) 470-5805.
Note: If transferring, the receiving department should submit a ticket for transfer of access, NOT the current department.

USA J#: \|	Email Address:	Dept/Org ID: \|
Transferring to: \|	New Title:	New Manager:
Click here to request a J Number

I am the Manager/Supervisor

Enter Manager/Supervisor Information

First Name: \|	Last Name: \|
Email Address: \|
Office Phone: \|	Mobile Phone:

Secondary Contact Information

First Name:	Last Name:
Email Address:
Office Phone:	Mobile Phone:

Provider Information

Provider Type:
|

Primary Specialty (Taxonomy):
|

Secondary Specialty (Taxonomy):

Title (MD, PA, PA-C, etc.):

Provider/MSI#:

No Admitting Privilege

Admitting Privilege UH

Admitting Privilege CW

SSN: Show/Hide

DOB (mm/dd/yyyy):

Please attach an NPI Form
NPI: | |

DEA#:

Medical License #:	Issuing State:
If Provider does not have a J-Number, please enter their home address:

Office Address: \|
Specify if Other: \|
Phone #(&ext): \|	Wireless #:
FAX #:

Request Access

Access Role: \| Select Position *Other - Specify in Comments Accountant Accounts Payable Advanced Endoscopy Scrub Tech Advanced MA AP Cytotechnologist AP Histotechnologist AP Lab Assistant AP Secretary Athletic Trainer Auburn Pharmacy Student Audiologist Billing Specialist Burn Unit RN Care Access Associate Care Access Referral Specialist Care Management CCCA Clinical Dietitian Clinical Pharmacist Clinical Programmer Clinical Transformation Specialist Clinician Coder Coordinator Practice Operations CRNA CRNP Custodial Worker CW Cashier CW Clinical Psychologist CW Medical Lab Technologist CW Medical Records CW NICU RN CW Patient Access Rep CW Pharmacist CW Pharmacy Technician CW PICU RN CW Respiratory Therapist CW RN CW ROI Specialist CW RTN L&D CW Secretary CW Security Officer CW Speech Language Pathologist CW Ward Clerk Desktop Support Technician Digital Marketing Specialist EEG Technician External Research Monitor - Clinical Trials Fairhope Pediatrics Clinical Nurse Practitioner Help Desk Technician HIM Clerk HIM Coder Hospital Administrator HouseStaff HR Assistant Informatics Specialist Internal Audit IT and Biomedical Trainer IT Audit Cleark IT Clinical Lab Coordinator IT Quality and Compliance IT Security Laboratory Assistant LPN MA Manager Employee Assistance Program Manager Practice Operations Marketing MD Medical Student - VIEW ONLY Medical Student Provider Medical Teaching Technologist NGRNP Nuance Scribe Nurse Manager Nurse Practitioner Student Nursing Instructor OB Technician Occupational Therapist Occupational Therapy Student Paramedic Patient Relations Coordinator Patient Transport Aide PCA Pharmacy Student Phlebotomist Physical Therapist Physical Therapy Assistant Physical Therapy Student Physicians Assistant Physicians Assistant Student Preservice Representative PRN Sitter Project Manager Psychologist Student Purchasing Specialist Quality and Performance Improvement Coordinator Radiologic Student Technologist Radiologic Technologist Radiologist Recruiter Respiratory Therapy Assistant Respiratory Therapy Student Respiratory Therapy Tech RN Scribe Speech Therapist Speech Therapy Student SPM Sterile Processing Tech Strada Administrative Assistant Student Nurse Telemetry Technician Temp RN Transfer Center Specialist Trauma Scrub Tech Travel RN UH Clinical Laboratory Medical Tech UH Clinical Laboratory Phlebotomist UH Credentialing Specialist UH Department Assistant UH Diagnostic Scheduler UH Medical Records DRG/APC Coordinator UH Patient Access Rep UH Pharmacist UH Pharmacy UH Pharmacy Tech UH Quality UH RN UH Secretary UH Security Guard UH Social Worker UH Sterile Processing Tech UH Supply Inventory Technician UH Trauma Registrar UH Ward Clerk Ultrasonographer Vulcan Radiologist		Access Role: \| Select Vendor *Other, Specify in Comments ACS Coders Alta Pointe Vendor Coastal Neurology Institute Coronis Health Vendor CRS Contracted Employee Data Abstractor Dr. Ronald Clark (OBGYN) Ensemble Health Partner Experian Information Technology Franklin Primary Care Gulf Coast Pediatric Care Gulf Coast Total Care Harmony Healthcare IT Leaders Hit_That_Noggin Intellis Management Legacy of Hope Users Nuance Communications Optum Advisory Board Phreesia Senior Client Success Associate PPM Partners Pulmonary Associates of Mobile Quest Diagnostics Scribekick Snelling Contract Labor Temp Softek Vendors Synergy IT TekLinks TEKSystems The Bienville Group_Pulmonary Associate of Mobile_ PC _ Billing United Healthcare Rep Vulcan Imaging/MSN billing Vulcan Radiology_MSN Healthcare Solutions		Title: \|
Needs Pharmacy Technician Training Program?
Office/Work Phone:	Set up like: \| Must be current, not terminated user

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