EMPLOYEE HANDBOOK
SUNY College of Optometry will supply access to its University Eye Center clinical systems for all authorized staff and providers Please fill out and return this signed form to the Office of Information Technology (IT) Help Desk via interoffice mail or fax to 212-938-5723. For questions, contact the IT Help Desk at 212-938-5730.
Last Name : __________________________ First Name : _____________________________ MI: ________ Title: _____________________________________ Class Year/Dept. :_______________________ Email Address ( other than SUNY ):________________________________________
Request Purpose:
New
Modify
Date access change is required: __________
Has user had access to clinical systems or other network systems at any time in the past? Circle One: Y / N If yes, please provide username(s):__________________________________________ Request Type Enterprise: SUNY Network Email Other __________________ NextGen: Practice Mgmt EHR Optik Other __________________
Security Groups: Provider Clinical/Tech Staff
Front Desk/Sched/MedRec Mgr Billing/AR Collections Mgr
Front Desk/Scheduling Staff Billing/AR Collections Staff
Medical Records Staff
Nursing
Optical Mgr
Optical Mid-Level
Optical Staff
Student/Class of _________
CVRC
Social Work
Social Work Intern
Resident
Other ______________
IF PROVIDER : (Requires NextGen EHR License) Rendering Provider? Circle One: Y / N
State Lic. No.:__________________ NPI No.:_______________ Degree(s):______________________________________ DEA No.:________________ Taxonomy Code: ____________________________SPI No.:____________________ Specialty:________________ Payer Name:___________________ Provider Type:______________________ Payer ID:__________________________
Comments/Additional Information: ______________________________________________________________________
___________________________________________________
_____________________
Clinical Administration
Date
97
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