Bon Secours :: Physician VPN Access Form

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

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

* Physician First Name:
* Physician Middle Initial:
* Physician Last Name:
* Office Address:
* Phone:
* Email Address:
* System(s) Physician will access:	drsweb
Physician 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 Signature: Physician Liaison Signature: