INFORMATION ACCESS REQUEST FORM EPIC ACCESS - New ID - Update Existing ID - Delete Existing ID

Oct 13, 2026

Information Access Request Form EPIC Access用于申请与管理对University Health System相关信息系统的访问权限。表单要求填写请求人姓名、部门、网络登录/用户ID、联系电话及凭证信息，并选择访问类型与角色范围（如Review Only、Coder、Billing、DataSearch等）。同时提供更新或删除既有ID的选项，并包含给办公室使用的完成日期与签署信息。文件还附带保密协议，说明账号与密码唯一性、离开工作站需终止会话、遵守保密义务及违规可能导致的权限撤销与纪律处分。

LanguageEnglish

CategoryForms

FormatPDF

Pages3

Reading Time1 min

AccessFree to download

INFORMATION ACCESS REQUEST FORM

USER INFORMATION

ACCESS REQUEST TYPES

FOR OFFICE USE

CONFIDENTIALITY AGREEMENT

INFORMATION ACCESS REQUEST FORM PLEASE SUBMIT THIS COVERSHEET WITH ALL ACCESS REQUESTS-BOTH NEW IDS AND UPDATES Please complete all of the information below. Incomplete forms will be rejected. TODAY’S DATE: START DATE: USER’S NAME: __________________________________________________________ LAST NAME FIRST NAME MIDDLE INITIAL LAST 4 DIGITS OF THE USER’S SSN: DEPARTMENT NAME: NETWORK USER ID: EMPLOYEE’S TITLE: PRIMARY WORK LOCATION: (UH, UHCD, UFHCN, UFHCNW, UFHCSW, UFHCSE, UHBC, UCCH, DHCS, UTHSC, CTRC, UPG, ETC.) RC NUMBER: ______________ PHONE/PAGER NUMBER: EXT. CREDENTIAL: __________ (MD, PA, MS3, MS4, RN, CRRT, LVN, etc.) PROVIDER ID\#: DEA\#: DPS\#: State Lic \#: HOUSESTAFF DEA\#: AM1472579 DPS\#: 10046768 State Lic \#: FACULTY HOUSESTAFF/RESIDENT Military Rotator ( to ) ALLIED HEALTH W/ PRESCRIPTIVE AUTHORITY Visiting Medical Student ( to ) Authorization letter from UT Registrar’s office must be attached. Requests without authorization will be rejected. Contract/temporary ( to ) Researcher or Research Monitor ( to ) for IRB\# AUTHORIZATION: (DIRECTOR/SUPERVISOR) PRINT: NAME TITLE SIGNATURE: E-MAIL ADDRESS FOR NOTIFICATION: (not required if your email [is @uhs-sa.com](is @uhs-sa.com)) Have any questions? Call Data Security at (210) 358-0640. You can scan and email completed access requests to [DataSecurityScannedRequests@uhs-sa.com](DataSecurityScannedRequests@uhs-sa.com), fax them to (210) 702-4010, or route them to us at MS124-1. Rev. 07/14 INFORMATION ACCESS REQUEST FORM EPIC ACCESS USER’S NAME: NETWORK LOGIN ID: SUPERVISOR’S SIGNATURE: ISSUE NEW ID | | UPDATE EXISTING ID | | | --- | --- | --- | DELETE EXISTING ID SELECT THE APPROPRIATE: Review Only (Can review charts but not edit data) Review Only with Reporting (Can review charts but not edit data; report access) Coder Billing MedData DataSearch Trend Optum UT Surgeon Clinical Support Staff UT Surgeon Administrative Support Staff IR Radiologist Radiologist Breast Imaging Radiologist Radiology Physician Assistant Cardiology Nurse Cardiology LVN Cardiology MA Cardiology Clinic Scribe Cardiology Practice Manager Cardiology Practice Supervisor Cardiology Benefits Coordinator Front Desk Referral Coordinator Concierge/Greeter Ophthalmology Tech Ophthalmology Clinic Manager Ophthalmology Front Desk Sr Admin Asst Admin Assist Data Coordinator Nurse Coordinator Transplant Biller South Texas Renal Group Texas Liver Institute CFL Oncology Nurse Orthotist/Prosthetist Emergency Service Project Manager Medical Student Nurse Practitioner Student Nursing Student Pharmacy Student Physical Therapy Student Occupational Therapy Student Speech/Language Pathology Student Respiratory Therapy Student FOR OFFICE USE: DATE COMPLETED: COMPLETED BY: Rev 03/2020 UNIVERSITY HEALTH SYSTEM CONFIDENTIALITY AGREEMENT I, the undersigned, hereby acknowledge receipt of a 4. Issuance of New Userid and Password. If I userid and password giving me access to the Hospital have any reason to believe that the confidentiality of Information System of the University Health System, my userid and password has been compromised, IBexar County, Texas (hereafter referred to as the will notify the Data Security Administrator University Health System) computer system. I immediately so that the suspect userid and password understand and acknowledge that this userid and may be deleted and a new userid and password password combination is unique to me and is the assigned to me. electronic equivalent of my signature, with no difference in liability existing between my written 5. Responsibility for Self. I recognize that I am and electronic signatures. responsible for all actions performed at a workstation activated with my userid and password; therefore, I I further understand that this userid and password will termina

FAQs

需要填写哪些关键信息来提交信息访问请求？

需填写请求人姓名、部门、网络用户ID、员工职位、主要工作地点、RC number与联系电话/分机，以及凭证类型等，并选择适当的访问范围。

表单如何区分“申请新ID”“更新现有ID”和“删除现有ID”？

在EPIC Access表单部分有“ISSUE NEW ID”“UPDATE EXISTING ID”“DELETE EXISTING ID”选项，并要求勾选或选择对应的处理方式与授权签署信息。

保密协议中对账号与密码有哪些核心要求？

协议强调userid与密码组合唯一且作为电子签名等效；需认识到所有在该账号下的行为由本人负责，并在离开工作站前终止会话。

若违反保密或访问条件会产生什么后果？

文件说明违反条件可能导致计算机访问被撤销、员工被终止雇用、非员工被拒绝医院访问以及其他纪律处分。

Oct 13, 2026

Upload by Mary Man