Dashboard Access Request for Employees Form

Incident #: Work Order #: PITC Name:

INFORMATION TECHNOLOGY DEPARTMENT PHYSICIAN/ALLIED HEALTH PROFESSIONAL APPLICATION ACCESS FORM

All information MUST be typed or printed in all fields. Information about person for whom application is being requested: First and Last Name (Please include middle initial) Provider ID or # Title Specialty Address Phone Email Cell Practice Name AD User Name Office Manager BHSF Employee Yes No

Physician Group Members:

(Required for accurate group census) (Attach separate sheet if necessary)

Please check all Baptist Health South Florida facilities where you have privileges: Hospitals: Urgent Care Centers: Baptist Hospital BHC - BAP HLTH CTR URG CAR WST - WESTON UC - WST Baptist Outpatient Services BUC - BRICKELL URG CARE CWU - COUNTRY WALK UC Doctors Hospital CSU - CORAL SPRINGS UC-CSU PBU - PALMETTO BAY UC-PBU Homestead Hospital DAU - DAVIE UC - DAU KLU - KENDALE LAKES UC-KLU Mariners Hospital DUC - DORAL URG CARE-DUC KWU - WEST KENDALL URG-KWU MASC BHM GDU - CORAL GABLES UC-GDU PIN - PINECREST UC-PIN MASC SMH MLU - MIAMI LAKES UC-MLU TUC - TAMIAMI URG CARE-TUC South Miami Hospital PPU - PEMB PINES UC-PPU WUC - WESTCHESTER URG -WUC West Kendall Baptist Hospital UUC - UNIVERSITY UC-UUC Please check if you are a New User or would like to Revise access

Please check all the applications where access is needed: Internet (For access to the Internet) Dashboard (For access to applications remotely) T-Systems (For access to ED clinical documentation) Syngo-Radiology (Radiology dept. use and/or readership Must fill out T-Systems Security Form. purposes) (Please check only one) Anesthesiologist Cardiovascular Radiologist PACS (For access to Picture Archive Communication System) AD - Network Login (For access to BHSF computers) (Please check only one) Radiologist BCVI Physician ED Physician Essentris BHM HH SMH WKBH ICU Physician NICU Physician Referring Physician Sovera (For access to Medical Records) Baptist Anesthesia Pyxis Anesthesia Endo IVR-A LDR MRI

*** Net Access and Dashboard are for PC ONLY. MAC is not supported. Ver4.9-.786.533.9931-TERMMB-07.03.2012-SEC

Net Access (For access to clinical Baptist Pyxis Medstation BHM patient information) SMH (A member of your office staff (1) per Anesthesia physician may also have NetAccess) Incident #:

Work Order #: PITC Name:

Please check all the applications where access is needed: (continued) Ovation Please select one: Baptist Author Baptist Review Only Author KinetDx / WebPro NeoData Addition Modification NOTE TO BA: User will need to be added to the AG-NeoData4-SM / AG-NeoData4-BH groups. Modification (if applicable): Unit Authorization: BHM SMH Job Class: SDN-B SDN-ARNP CCNS CCNS-ARNP VIEW/PRINT SUPERUSER SDN/CCNS Does their name have to be added to the Preparer drop down list? Yes No Does their name have to be added to the Attending MD drop down list? Yes No

Wireless Network Access Application Type: Administrative Clinical Device Type: Remote Applications Needed: BHSF Citrix Remote Access Token # Remote Applications Needed:

By signing below you have read and agreed to BHSF Policy 105 in your package.

Signature Date

You are requesting a password and user ID to the Document Management System (“DMS”). The DMS contains confidential patient information. Confidential patient information may only be retrieved and viewed by physicians, nurses and hospital personnel who are authorized to access such information. In order to maintain patient confidentiality, it is extremely important that you rigorously safeguard your password. You are the only person authorized to use the password assigned to you, therefore, you will be held accountable if someone else uses it. DO NOT GIVE YOUR PASSWORD TO ANYONE; this includes colleagues, nursing personnel, hospital personnel, office staff and everyone other than you.

An audit trail is created every time your password is used to access the system and the audit trail is reviewed on a regular basis. UNAUTHORIZED USE OF DMS PASSWORDS AND USE OF ANOTHER AUTHORIZED USERS PASSWORD IS STRICTLY PROHIBITED AND MAY SUBJECT YOU TO DISCIPLINARY ACTION INCLUDING BUT NOT LIMITED TO LOSS OF MEDICAL STAFF PRIVILEGES. I have read and understand the above and agree to be bound by same.

Signature Date

Please return completed form with application to Medical Staff Office. A representative from the PITC team will contact you with training dates and times shortly after credentialing process has been completed.