INFORMATION ACCESS REQUEST FORM

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INFORMATION ACCESS REQUEST form PLEASE SUBMIT THIS COVERSHEET WITH ALL ACCESS REQUESTS-BOTH NEW IDS AND UPDATES Please complete all of the INFORMATION below. Incomplete forms will be rejected. TODAY S DATE: ________________ START DATE: ______________ USER S NAME: ________________________________________ __________________ LAST NAME FIRST NAME MIDDLE INITIAL LAST 4 DIGIT S OF THE USER S SSN: _________________________ DEPARTMENT NAME: __________________________________ NETWORK USER ID: ________________________________________ __ EMPLOYEE S TITLE: ________________________________________ _ PRIMARY WORK LOCATION: ________________________________________ ___________________ (UH, UHCD, UFHCN, UFHCNW, UFHCSW, UFHCSE, UHBC, UCCH, DHCS, UTHSC, CTRC, UPG, ETC.)

INFORMATION ACCESS REQUEST FORM REMOTE ACCESS REQUEST FORM (Must be accompanied by the Information Access Request Form Coversheet) Remote Access may be provided to exempt employees, physicians with active UHS privileges, and contracted users outside the Health

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