Epic Access & Training Request 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.

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: *

Type of New Hire Request: *

Staff

Student

Contract

Other

If you are submitting an access request for a new hire, please click here to print a copy of the UH Confidentiality and Network Access Agreement.

Attach completed Confidentiality & Network Access Agreement:

Type of User Access Termination: *

Routine

Immediate (call the Helpdesk at (706) 774-5050, option 1 to report)

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):

Staff Role/Job Responsibilities (indicate if the user's access should mirror another user; provide that user's name and UH Access ID. *

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: