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

The purpose of this form is to inactivate access to networked computer system(s) in the Bon Secours Richmond Health Corporation. If the inactivation is of a sensitive nature, require prompt action and notification to Information Services. 

Required fields are noted with an asterisk (*).

First Name *
Middle Initial *
Last Name *

If you do not have an email account, please use the default email address - no_email_account@bshsi.org - in the field below.

Email Address *
Inactivation Effective Date *
Richmond Academy Number *

Inactivation Facility (check all that apply)

 MRMC
 RCH
 SMH
 SFMC
Affiliated Practice Name*
Please add any additional information to assist with Inactivation
Supervisor/Manager Authorization *
* required fields

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