Security Work Order by fvu21144

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									                                                                      Children's Hospital of Pittsburgh
                                                                        User Security Access Form
                                           E-Mail form to ISD CHP Security
User Information
  Last name, First Name MI NEEDS TO BE FILLED IN              CHP Manager/Sponsor Name Sara McIntire, MD/Marlynn Haigh

                                   Title Medical Student                                           CHP Manager/Sponsor Title Sara McIntire, MD/Marlynn Haigh
                                           MD, DO, PA, etc.
                       Date of Birth NEEDS TO BE FILLED IN
                                                                                              CHP Manager/Sponsor Phone # 8260
                           Job Title Medical Student

                       Cost Center 51801                                                                           Employee Status CHP Employee
                                                                                                         CHP Employee, CCP or Foundation, UPMC Employee, Contractor, or Vendor
               Department Name Pediatrics
                                                                                                                 Employee Number
   SS#, Visa #, or Passport # NEEDS TO BE FILLED IN                                                                                                        5-digit employee #
                                                                                                    Security Action Requested
       Mother's Maiden Name NEEDS TO BE FILLED IN                                                               New User Account, Modify User Access, Delete User Access


                                                                                                                                          The manager is responsible to ensure that a
                                                                                                  YES a confidentiality form is on file   confidentiality form is on file: For employees send
                                                                                                                                          forms to HR, and for Non-employees, retain form in
                                                                                                                                          the business area.


                                                                                   Account Information
                                                                                                                                          Other:
     CHP Cerner           Express Query                 PeopleSoft Finance           EMStation/VitalWorks              Network
                                                                                                                                                                                                CHP Employee
     DeRoyal              Invision                      PeopleSoft HR                EMTrack/VitalWorks                Outlook (e-mail)   NEEDS LOGICARE ALSO
     Doc Imaging          Kronos                        Quest Vista                                                                                                                             CCP or Foundation
     MARS                 UPMC Upay                     UPMC VPN                     UPMC Stentor
                                                                                                                                                                                                UPMC Employee
                                                                                                                                                                                                Contractor
Cerner Accounts                                                                                                                           Other:                                                Vendor
Choose the Cerner Role:                                       If licensed Ellen Lipsitz has been contacted with License # and SS#         Medical Student                                       Click for list of roles
Click for list of roles                                                                                                                                                                         Acting Intern
                                                              If Attending Physician, Medical Affairs has confirmed                                                                             Admin
                                                                                                                                                                                                Adolescent Admin
Document Imaging                                                                                                                                                                                Ancillary/Other Systems

            PFS Administrator              PFS             Registration               Administration             Registration & Administration        PFS Scanner           Vendor
                                                                                                                                                                                                Anesthesia Admin
                                                                                                                                                                                                Asthma Admin
Invision Accounts                                                                                                                         Other:                                                Auditor

                                MR Coder/Abstractor              Pt Access - Inpt & Outpt            Pt Accounting - Collector Wkst
      Nursing
                                MR Clerk                         Pt Access - Outpt Only              Pt Accounting - No Collector Wkst
      General Inquiry
                                MR Supervisor                    Pt Access/MR Rep                    Pt Access Supervisor                                                                       Care Coordination
                                                                                                                                                                                                Cath Admin
CHP MARS                                                                                                                                  Other:                                                Child Dev Admin
                                                                                                                                          Include Home Address if accessing
               Access from CHP network               Access from Internet (monthly fee for UPMC SecureID)
                                                                                                                                          Mars from Internet so SecurID Key FOB                 Child Life
          Reviewer's Name                                                                                                                 can be mailed. UPMC Requires this                     CIS DBA1
  Reviewer's e-mail address                                                                                                               information.                                          CIS DBA2
                                                                                                                                                                                                Clinic Staff
EMStation/VitalWorks                                                                                                                      Other:                                                CSR

    Clerk         PA             NP         Nurse         Medical Student           Fellow           Staff Physician          Resident
                                                                                                                                                                                                DBA
                                                                                                                                                                                                Diagnostic Referral Admin
EMTrack/VitalWorks                                                                                                                        Other:                                                Dietitian Admin

       Clerk            Nurse              Fellow         Medical Student            Resident             Staff Physician                                                                       Endocrine Admin
                                                                                                                                                                                                ENT Admin
PeopleSoft HR                                                                                                                             Other:                                                Enterstomal Admin

    HR Benefits User            HR Recruitment User           HR Training User            E-pay
                                                                                                                                                                                                GI Admin
                                                                                                                                                                                                Help Desk Staff
PeopleSoft Finance                                                                                                                        Other:                                                Hematology Admin

     Acct Payable           Asset Mgt               Gen Ledger            Grants             Inventory           Purchasing
                                                                                                                                                                                                HUC/PCT
                                                                                                                                                                                                Help Desk Staff
UPMC VPN                                                                                                                                  Other:                                                Hematology Admin
Remote Access Connectivity Agreement
Management is required to retain a signed Remote Services Agreement (link above)
Home Address: (Used to Mail the Security key FOB)                                                                                                                                               Medical Student



                                                                                                                                                                                                Neuro Admin
                                                                                                                                                                                                Help Desk Staff
Notes:                                                                                                                                                                                          Neuro Physiology
                                                                                                                                                                                                Neurosurgery Admin
                                                                                                                                                                                                No Access Staff
                                                                                                                                                                                                Nursing QA
                                                                                                                                                                                                NP/PA Admin


                                                                                                                                                                                                Nursing Staff
Manager's Signature or e-mail header is required as approval. Please have the manager or director forward the
completed form to ISD CHP Security. (Click on file, Send to, As attachment)                                                                                                                     Nursing Student

								
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