Remote Access Request
Online Form

* denotes required field

 

Requester's Name *

Physician Office/Company *

Physician Office/Company Address
(street address, city, state and zip) *

Phone Number *
 -

Fax Number *
 -

Email Address *


List the users that will need remote access *
First Name Middle Initial Last Name Mother's Maiden Name


List the systems you wish to have access to and the office locations where access will be installed *

Please select business need for remote access *


Prior to being granted access, a signed End User Security Statement must be signed and returned to the
SRHS Information Systems department - fax: (615) 328-6665.
***Click here for the End User Security Policy Notification***


I attest that I have read the Remote Access Policy and agree to abide by its terms. *
 Checking yes is the equivalent of your signature. **Remote Access Policy**
Yes, I agree