Epic Access & Training Form

All requests for user access, terminations and provider records should be submitted to the Helpdesk by an Authorized Requestor. Managers are Authorized Requestors. Anyone else designated to be an Authorized Requestor must be identified in advance, through the Helpdesk (helpdesk@uh.org), by the Manager to avoid service delays. By completing this form, you are requesting system access, to include user ID (for non-University Health Care System employees) and Epic Training. An additional Helpdesk ticket is not required.

By checking this box, I am verifying that I am an Authorized Requestor in a manager/director role or a designated authorized requestor. *

Verified

To access the Epic Training Calendar, log into Epic and open from your Learning Home Page.

Note: Please allow 5 business days to complete your request. Complete the form and click Submit.

Authorized Requestor's Name: *

Authorized Requestor's Email Address: *

Authorized Requestor's Phone Number: *

Name of Practice/Dept: *

Type of Access Request: *

Are you requesting this training for multiple trainees? *

List the name and user ID of the trainees below.

+-

Explain the type of training or indicate the class that is required: *

Provide Trainee's available dates/times for training:

Type of New Hire Request: *

Staff

Student

Contract

Other

If you are submitting an access request for a new hire AND you are not an employee of University Health Care System, please click here to print a copy of the UH Confidentiality and Network Access Agreement.

Attach completed Confidentiality & Network Access Agreement:

Effective Date of Change: *

User's Name: *

UH Access ID (if known):

Credentials:

User's Phone Number:

User's Email:

Home Practice/Department (if applicable):

Will the user work in an Ambulatory office? *

Yes

No

Ambulatory classes: *

Will the user work in Admission/Discharge/Transfer? *

Yes

No

Admission/Discharge/Transfer classes: *

Will the user work in Cupid? *

Yes

No

Cupid classes: *

Will the user work in Emergency Dept? *

Yes

No

Emergency Dept classes: *

ED RN

ED Tech (EMT, PCA)

ED Advanced Tech (LPN)

Other Other

Will the user work in Hospital Outpatient? *

Yes

No

Hospital Outpatient classes: *

Will the user work in Hospital Billing? *

Yes

No

Hospital Billing (UH employee) classes: *

Will the user work in Hospital Billing Contract? *

Yes

No

Hospital Billing Contract classes: *

HB View Only

HB View Only w/Acct Notes

Other Other

Will the user work in Inpatient? *

Yes

No

Inpatient classes: *

Will the user work in Health Information Management? *

Yes

No

Health Information Management classes: *

Will the user work in Optime/Anesthesia? *

Yes

No

Optime/Anesthesia classes: *

Will the user work in Professional Billing? *

Yes

No

Professional Billing classes: *

Will the user work in Professional Billing Contract? *

Yes

No

Professional Billing Contract classes: *

Will the user work in Radiant? *

Yes

No

Radiant classes: *

Will the user work in Willow Pharmacy? *

Yes

No

Willow Pharmacy classes: *

Pharmacist

Pharmacy technician

Pharmacy Student (for students on rotation)

Other Other

Who will be the student's preceptor? *

Student's contact number: *

Student's email address: *

Student's Start Date: * +

Student's End Date: * +

Staff Role/Job Responsibilities: *

Access to Other Departments?: *

Please list additional departments to which the user requires access: *

Is access the same across these departments? *

Referral Workqueues (please list incoming and/or outgoing; if access to workqueues in additional departments is required, please list those as well):

Comments or other instructions: