New User Request Request Type*New Employee AccountRemove Employee(s) AccountRequest Access Change for existing AccountName of Person Making the Request* Provider Name* Email of Person Making the Request* Provider Site User Account InformationAccount Email* Account Permissions*Model After Existing StaffSelect Access for AccountAdd/Edit Account* Model Permissions After NPI Number Select Access LevelsIncident Report Data EntryIncident Report Review/Sign-offAccounts Payable Claims Data EntryHospital Continued Stay Review (Utilization Review)Mental Health Provider ClinicianContract Clinician (progress notes, OT notes, psychological or nutrition assessments)Job Title Phone Number*Names of Staff Who No Longer Work for Your OrganizationFax NumberRemove the following accounts from E.IIRemove Staff #1 Effective Date #1 MM slash DD slash YYYY Remove Staff #2 Effective Date #2 MM slash DD slash YYYY Remove Staff #3 Effective Date #3 MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
