Bon Secours :: For Physicians :: Inactivate Physician or Physician Staff Form

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Bon Secours Health System Computer Security Inactivation Form - Physician and Physician Staff

The purpose of this form is to inactivate access to networked computer system(s) in the Bon Secours Richmond Health Corporation. Fill out form completely. Inactivations, especially of a sensitive nature, require prompt action and notification to Information Services. This form must be filled out completely prior to processing by Information Services.

*Required Information. (Please enter all required information in order to avoid having to re-key each field.)

* First Name:
* Middle Initial:
* Last Name:
* Email Address:	If you do not have an email account, please use the default above.
* Current Date or Inactivation Effective Date:	Month Day Year
* Practice Name:
* Richmond Academy Number:
Inactivation Facility (check all that apply)	MRMC RCH SMH SFMC All Facilities
Please add any additional information to assist with Inactivation:
*Supervisor/Manager Authorization: