Computer Security Access Form - WorkForce Member

Managers should complete this form for additional account access to existing workforce members, creation of new vendor/contractor accounts and employee transfers.

This form is not required for new employees who only require ADS, Outlook, EZAccess, and ConnectCare.  In these instances Information Services is notified by Human Resources of the new hire as soon as they complete their background check and health assessment.

 
Type of Request: *
Workforce Member's Information
First Name: *
Middle Initial: (N/A if unknown) *
Last Name: *
Vendor/Contractor Non BSHSI email

Please provide the ADS account for changes to existing accounts and extensions of vendor/contractor accounts.

Current ADS Account Name
Forms submitted less than 10 days prior to when access is needed may not be processed by the requested start date. Operations require at least 10 days to process Security Access Forms.
Start Date *
Job Title: *
Supervisor Name *
Supervisor Title: *
Supervisor Phone: *
Supervisor Email *

(For Vendor/Contractor Staff, please include the vendor/agency company name)

Vendor/Contractor/Agency Company (If Bon Secours Employee enter BSHSI Employee) *

 

Facility: *
Department or Business Name: *

Applications: Please check each application the workforce member will require.

 ADS
 MS Outlook (if you check this box you must enter in a cost center code below)
Outlook Cost Center Code - Required if Outlook Requested
 Healthstream (DO NOT select if user will be a Bon Secours Employee)
 ConnectCare (ADS required)
 Radiology (Novius)
 Athena - When you request Athena, you must enter the work force member's date of birth.
Athena Date of Birth
 Centricity Perinatal (NOT Centricity PACS)
 Cerner/Bridge MedAdmin
 Citrix
 CoPath
 CPM Module
 GlucoStabilizer
 Kronos - When you request Kronos, you must enter facility and cost center numbers.
Kronos Cost Center Number
Kronos Facility Number
 Lstat
 MedNet
 MUSE
 Neuroworkbench (EEG or EMU)
 One Staff - When you request One Staff, you must enter facility and cost center numbers.
One Staff Cost Center Number
One Staff Facility Number
 PACS (Cardiology)
 PACS (Radiology)
 PACS Cube
 Pixys
 Powerscribe
 SMS Pharmacy
 Softmed
 Softmed/Citrix
 Softmed ESA
 Softmed Chart View
 Sovera
 Stentor
 Sunquest
 Sunquest Collection Manager (SMH and SS Only)
 Trendstar

Please List any share drive the Work force Member will require.

Shared Drive Mapping
Please add any additional application not listed above or other information to assist with access creation.
Patient Financial Services Access Request:
 Xactimed
 iSuite/eFR
 Payor Website
 Affinity
Affinity User to Mirror
 RevProtect
 Rev Recover
 Medicare
Last Four of SSN (Patient Financial Request Only)

I verify that the Workforce Member listed on this form requires the access indicated to fulfill their job responsibilities. I further agree that, if the individual is not an employee of Bon Secours-Richmond Health System, I take full responsibility for any acts the individual performs on the networked computer system(s).

Supervisor/Manager Acknowledgement *
Email Address for Confirmation Letter *
* required fields

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Bon Secours International| Sisters of Bon Secours USA| Bon Secours Health System