Bon Secours :: For Physicians :: VPN Access Physician Form

Save time by filling out your vpn access request online.

Bon Secours Health System Physician or Physician Staff Qualification Form for Remote Access via Virtual Private Network (VPN)

Additional documents for review:

VPN Request/Renewal Policy
VPN Instructions

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

* First Name:
* Middle Initial:
* Last Name:
* Practice/Office Name:
* Office Address:
* Phone:
* Email Address:
* System(s) Physician or Staff will access:	drsweb
Physician or Staff Liason:
Liaison Phone:
Liaison E-mail:
* VPN Access Required FROM:
* VPN Access Required Until:	(UNTIL date cannot exceed 12 months beyond FROM date. You must submit a new Qualification Form to extend VPN access beyond 12 months.)
	You can click here to view instructions.
* PC Brand/Model:
* Operating System:
* Service Pack Level:
* Security/Vulnerability Patches Current:
* Anti-Virus Software Package:
* Engine Level:
* DAT/Signature Level:
I will maintain my laptop at the current BSHSI approved Anti-Virus Engine-DAT/Signature Level and Security/Vulnerabiltiy Patch Level. I will notify BSHSI immediately when VPN access is no longer required. I acknowledge BSHSI may examine my laptop as needed to validate that proper Anti-Virus and Patch Levels are installed. BSHSI will make every effort to perform the examination at a mutually convenient time. *Physician or Staff Signature: Physician or Staff Liaison Signature: