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Bon Secours Health System Physician or Physician Staff Qualification Form for Remote Access via Virtual Private Network (VPN)

Additional documents for review:

VPN Request/Renewal Policy
VPN Instructions

First Name *
Middle Initial *
Last Name *
Practice/Office Name: *
Office Address *
Office Phone *
Email Address *
System(s) Physician or Staff will need to access *
Physician or Staff Liason
Liason Phone Number
Liason Email Address
VPN Access Required FROM Date *

(UNTIL date below cannot exceed 12 months beyond FROM date. You must submit a new Qualification Form to extend VPN access beyond 12 months.)

You can click here to view instructions. 

VPN Access Required UNTIL Date *
PC Brand/Model *
Operating System *
Security Pack Level *
Are Security/Vulnerability Patches Current? *
Anti-Virus Software Package *
Engine Level *
DAT/Signature Level *

I will maintain my laptop at the current BSHSI approved Anti-Virus Engine-DAT/Signature Level and Security/Vulnerabiltiy Patch Level. I will notify BSHSI immediately when VPN access is no longer required. I acknowledge BSHSI may examine my laptop as needed to validate that proper Anti-Virus and Patch Levels are installed. BSHSI will make every effort to perform the examination at a mutually convenient time.

Physician or Staff Signature *
Physician or Staff Liaison Signature
* required fields

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