Transcription of Internet Access Form
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Internet Access Form
Internet Access REQUEST/NEW USER APPLICATION form InformationFacility Type Hospital AmSurg HMO ALF Facility Name License Number AHCA/File # Contact Person Last First Phone number with extension ( ) - Ext : Contact Title E-mail address of the contact person By my signature, as the Administrator or Risk Manager, I request AHCA to grant Internet Access to the persons named in section #2, after applicant has read and signed section #3. I further acknowledge it is my responsibility to notify AHCA to deactivate the account at employment departure. of Individuals Authorized to Submit ReportsList the names and titles of the individuals authorized to submit reports. A separate account and user ID will be established for each person submitting reports to the Agency.
Therefore, prior to submitting a new user id/password application please make sure the administrator listed on the application is the current administrator of record on file with the appropriate licensing unit of …
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