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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