EXTERNAL USER ACCESS REQUEST FORM

ISD Security MD2800 -A Modified Form WILL NOT Be Accepted- Effective Date ____ /____ /____
All NEW requests must be accompanied by a completed User Affirmation Statement (Form 02-002F)
I. Security Access Requirements:

Mainframe/PMMIS: New User Change User Delete User

Network: New User Change User Delete User

II. User Information:

Name: _____________________________________ ______________________________ _________

( Last ) ( First ) ( MI )
Title: ______________________________________ Phone: __________________________________

Email: ____________________________________ Consultant Other _________________________

III. Mainframe Access Requirements:

Group # Worker-ID Type Site Control D

_______________ __________ ________ ________ (PMMIS Mainframe Report Access)

E/C Adj Lvl: L=___________ Health Plan ID(s): ___________________________________________

Mainframe/PMMIS User ID: __________________ Last 4 numbers of SSN: _______________

(for all new mainframe
users)
IV. Network Access Requirements:

Protected Directory: Path _____________________ ____________________________ Read Write

Fortis: Group Name(s): __________________________________________________________________

HEA plus: Group Name:_________________________________________________________________

SharePoint: Site Name:__________________________________________________________________

Cognos: Universe:____________________________ Universe: ________________________________

Other Application(s): _____________________________________________________________________

V. Security Administration:

Authorized By: x__________________________________________ Date: _____/_____/______

Title: ______________________________________ MD: __________ Phone: ________________

Received: __________ Completed: ___________ Notified: ___________ By: ____________

Rev 10/2018
 Instructions for External User Access Request Form

Effective Date: Enter the effective date of the request in format mm/dd/yy.

Section I, System Access Requirements:

System Access: Check the box(s) for the system access that is being requested and type of account action being requested. Mainframe
and Network may be checked if access to both systems is being requested or affected.

For Mainframe, complete sections II and III. For Network, complete sections II and IV.

Section II, User Information:

User Information: Enter the Name, Title, Phone, and E-Mail for the user that the account access is being requested.
For Network sign on ID’s, your middle initial is required.

Section III, Mainframe Access Requirements:

Group#: Enter the PMMIS Group Name for the requested access.

-Worker ID: If required, enter either the valid case number provided by the supervisor, or the users first and last initial and the last
four digits of the user SSN.

-Type: If required, enter the correct two-digit Type code from the PMMIS Type Code Table.

-Site: If required, enter the correct three-digit Site code from the PMMIS Site Code Table.

E/C Adjudication Level: If required, enter the valid two digit code (01-99)

Health Plan ID: Enter the valid six digit Health Plan ID(s).

Mainframe User ID: If the access of a current user is being Changed or Deleted, the requester should enter the user’s logon ID.

Last 4 Numbers of SSN: This is required for all New Mainframe access requests. It is used as identity verification for password resets.

Section IV, Network Access Requirements:

Protected Directory Path: Enter a valid path name that shows the location of the protected directory to be accessed. (I.e.
\\STORE06\G-Drive\Share\Data1). Indicate whether READ or WRITE access is being requested.

Fortis, HEAPlus, SharePoint : Check the box for each application being requested and enter the requested Group Name or Site Name.

Cognos: Check the box to request Cognos access and indicate the Universe(s) being
requested.

Other Applications: Indicate any access requested to other applications that are not listed.

Section V, Security Administration:

Security Administration: Security Administration section to be completed by the AHCCCS Security Administrator.