Bon Secours Health System Computer Security Access Form- Affiliated Physician Office Staff

The purpose of this form is to request access to networked computer system(s) in the Bon Secours Virginia Health Corporation. 

Managers should fill out this form for the staff member requesting access to any application.
Required fields are noted with an asterisk (*). 

BSHSI Market *
First name *
Middle Initial *
Last Name *
Employee Email Address *
Practice Name *
Practice Address *
Practice City *
Practice State *
Practice Zip *
Work Number *
Fax Number*
Job Title *

Check all that apply

 ADS
 HealthStream (Online training tool required for ConnectCare access)
 ConnectCare (If ConnectCare Link will be used, you must enter the associated physician of the pratice in the text box below)
Special Requests

I verify that the above named person is an employee and has a legitimate need to access networked computer systems managed by the Information Services department of the Bon Secours Virginia Health System to fulfill their job responsibilities. I further agree that, if the individual is not an employee of Bon Secours Virginia Health System, I take full responsibility for any acts the individual performs on the networked computer systems.

Supervisor/Manager Authorization *
Supervisor Email *
* required fields

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