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AEL Request Form

This document is a request form for physicians and office staff to access test result data through a web-based system. It contains information about the client's practice including contact details and preferences. Nine users are listed who will need access, and they must sign to agree to maintain patient confidentiality. Approval is needed from marketing and executive leadership before the IT department sets up each user's access and verifies data transmission.

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Sydney Morris
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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61 views2 pages

AEL Request Form

This document is a request form for physicians and office staff to access test result data through a web-based system. It contains information about the client's practice including contact details and preferences. Nine users are listed who will need access, and they must sign to agree to maintain patient confidentiality. Approval is needed from marketing and executive leadership before the IT department sets up each user's access and verifies data transmission.

Uploaded by

Sydney Morris
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Web LabWorks Results Request

Department of Information Technology


Client Information
Client Name: Client Codes (list all):

Address: City: State: Zip Code:

Office Contact: email address: Fax Number:

Client Preferences Information


Who is the client's CSA?
State of Tennessee - Mid-Cumberland Region
Does the client currently use LabWorks to order tests? Yes No
Does the client have internet access in the office? Yes No
Physician and Clinic Staff User Information
Name of Web LabWorks User Physician or Office Staff Member? View Results for which Client Code(s):

Physician Office Staff Member


Physician Office Staff Member
Physician Office Staff Member
Physician Office Staff Member
Physician Office Staff Member
Physician Office Staff Member
Physician Office Staff Member
Physician Office Staff Member
Physician Office Staff Member

Physician Office Staff Member


User Confidentiality Statement

I am aware of my responsibility to maintain the confidentiality of all patient related information. This includes verbal,
written, and /or computer information pertaining to data and /or results of patients. I further understand that my internet
access identifier, password, and /or secret code is not to be disclosed to any person.

USER SIGNATURE: DATE:

USER SIGNATURE: DATE:

USER SIGNATURE: DATE:

USER SIGNATURE: DATE:

USER SIGNATURE: DATE:

USER SIGNATURE: DATE:

USER SIGNATURE: DATE:

USER SIGNATURE: DATE:

USER SIGNATURE: DATE:

USER SIGNATURE: DATE:

Approval
Requested by: Date: Director of Marketing: Date:

Chief Financial Officer: Date: Executive Director: Date:

*****DELIVER TO COMPUTER OPERATIONS AFTER APPROVAL*****


Web LabWorks User Access Request rev. 04/28/03
TO BE COMPLETED BY I.T. DEPARTMENT PERSONNEL
Date Received: USER NAME:

Activity Summary
LabGEM Data Entry (Signature): Date: LabWorks Data Entry (Signature): Date:

Result Transmission Verified by: Date: Notification Letter and Instructions Sent to Client by: Date:

Notes

Web LabWorks User Access Request rev. 04/28/03

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