Application Access Request External

Application Access Request External

Access Request Type

Type of Entity*

Non-WTH Clinic

External ROI Entity

Post Acute Provider

Third Party Biller

Insurance Company

Other

Enter the type of entity*

User Information

Enter the user's full legal name. Nicknames are not accepted.

Requestor Last Name*

Requestor First Name*

Requestor Email Address*

Authorized Signer Email Address*

Enter the email address of the individual at your organization that is authorized to sign the System Access Agreement.

Client or Organization Name*

Address

Phone

Cell Phone*

Phone

Fax

Phone

What functions do you need to perform?*

Check all that apply.

View Patient Data

View Patient Charge Detail

HIM ROI Request

Make Outpatient Specialist Referral

Order Outpatient Imaging or Lab Tests

Enter Procedural or Surgical Orders

Enter Outpatient Infusion Orders

Physician Extender

Other

Other Functions Needed

With what WTH Service Lines do you most closely work?

If there is another user at your facility that has similar access, enter their name here.

I provide services in a WTH facility.

Have you worked in an Epic EHR at another facility in the last 12 months in the same job role as you are requesting?

Yes

List Epic applications in which you have previously worked.

If we need to contact someone other than the request user listed above to get more information about this request, who is the best person to contact?

Contact User Above

Contact Name*

Contact Email*

Contact Phone*

Phone

Send me a copy of my responses

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