athenaOne Access Request Form

athenaOne Access Request Form

Required Information

Today's Date*

Last Name*

First Name*

DOB*

UT EID*

6 or 7 digit UT EID For Example: jdd5555

New Hire Email*

Start Date of Employment*

Reason for Access*

Describe the details of the work you will perform with this access.

Job Title*

Position*

Select or enter value

Patient Care Location? (Provider)*

Select

Appointment Mapping*

Please list a provider whose appointment types should be mirrored in Athena.

Is EPCS (controlled meds) Setup Needed?*

Select

Name of User in Similar Role*

Please provide a user who has similar job functions in Athena.

Requested Athena Training Class

Please select the training class the new hire should attend (Not required for View Only user access requests).

Select

UTHA Department*

Select

Rehire or Transfer within same role?

Select

Additional Comments

Name of Requester*

Name of Approver*

Send me a copy of my responses