Providence Everett Medical Center
Access Authorization Form for Online Clinical Results
This form is required from all individuals, other than Providence employees, employed physicians, or
credentialed members of the Providence Everett Medical Center medical staff, seeking to gain access to
Providence Everett Medical Center's clinical information systems.
This form must be filled out completely in order to process request. Please print.
Access requires a Confidentiality and Nondisclosure Statement
Please return this form to your Office Administrator/ Office Manager. Forms submitted without authorizing
signatures will be returned to the requestor.
Type of Request: New (add a user) Change Delete (remove a user)
Legal Last Name: Legal First Name: M.I.
Name of Clinic/Practice Where Employed: E-mail Address: Work Phone:
Physician Office Staff OneHealthPort User ID:
Job Title: _______________________________________
Please indicate the physician/department you primarily support
Sponsoring Practitioner (required if requestor is not a member of the PEMC Medical Staff)
Name (print): Telephone:
Requestor's Signature: Today's Date:
Type of Access (select those which you are requesting):
ProvCare - select one of the following access levels:
Full Access: all patients' clinical & demographic information
Limited Access: your patients' clinical & demographic information from admission thru discharge + 72hrs
Facesheet only: all patients' insurance & demographic information (generally used for billing office staff)
Confidential Locations - requires department director authorization
Quantitative Sentinel - Fetal monitoring system. OB-related practitioners only. Requires authorization from Medical
Director, Pavilion Family Services. Full application access to Quantitative Sentinel is given only to in-house practitioners.
Includes OB Link, which provides limited web-based access to view fetal monitoring strips
OptiMed - Full Access to the OptiMed and OptiBrowse applications. Requires CVL department approval.
Network Account - Created within the PHS-WA domain to allow the user to access to OptiMed/OptiBrowse and/or dialup
Office Administrator / Office Manager:
When completed, please fax to PEMC Medical Staff Services, (425) 261-3095
Version 3.2 revised 05/12/05