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Surgery Scheduling Form - Excel

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					                                                                                                                                 Information Systems Department
                                                                                                                                         User Logon Account Request Form

                                                                                                                                 Submit Forms to Qic Code 22158 or Fax to 437-8536 (x48536)
                                                                                                                                 Please allow 2-3 business for turnaround


                                                                                                                                 (Questions on how to complete form, call 437-4503)
___ Add ___ Revise ___ Delete                                                 Please Print

____________________________________                     __________________                _________           __________________              ___________________________________
Last Name (required)                                     First Name (required)             MI (required)      Job Title (required)             Dept\ Work Loc\ Clinic\ Extension (required)

____________________________________                             ____________________________________                                       ____________
                                                                                                                                 __________________                        _________________
Manager's Name (required)                                        Manager's Signature (required)                                  Mgr's Phone Num (required)                QIC Code (required)

Forgot your Logon Id or Password? Complete Password Hint.                                                            Type of Password:         _____ Permanent             _____ Temporary

Mother's Maiden Name:     ____________________________                                                               Copy from User (Name): ______________________________________



APPLICATIONS
_____     Signature      (Ambulatory Care                         _____       PCSI         (Pharmacy)                             _____        Lawson         (Financial System)
                         Registration System)
_____        Invision\OAS Gold          (Hosp Reg\                _____       Grasp        (Patient Acuity)                       _____        DSS            (Decision Support)
                         Orders\Results)
_____        Radiology (Radiology Tracking\                       _____       CPM          (Surgery Scheduling)                   _____        RefTrak      (Referral Tracking)
                         Hospital Clinic Scheduling)                                                                                           Role (check appropriate box(s)
_____        SARX Pharmacy                                                                                                                ____ Submitter            ____ Med Clerk
                         (Pharmacy System)                                                                                                ____ Viewer               ____ Spec Clerk
_____        Meditech    (Laboratory System)                                                                                              ____ Ref Nurse            ____ Contact Staff

_____        Wellsoft     (Emergency Tracking)                                                                                     Email Address =
                                                                                                                                 (required - email address will be the Acct Login ID)
_____        CalWin (Social Services Web Access)                                                                                  _____       PACs (MagicWeb\ MagicView)


_____        Groupware (Policies & Procedures)                                                                                    _____        EKG (Muse)


                                                                                                                                  _____        Network        _____        E-Mail
Manager Authorization is required and this form will not be processed if required
information is not complete. The Manager certifies that the Confidentiality
Agreement is on file. Confirmation of setup of account will be sent to Manager                           ____________________________________                              _________________
via Qic Code or Email.                                                                                         Employee Signature (required)                               Date (required)
  IS Dept Use Only
E-Mail Address:                                                               Invision/OAS Gold/
                                                                              Sarx/RMS:                                                        Meditech ID:
Network User Name/
PACs/EKG/Groupware:                                                           Signature:                                                       Meditech PW:

ver11        05\01\06

				
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Description: Surgery Scheduling Form document sample