NARF - CBCC

User Information

All information is required.

User Type

Internal User

External User (Please attach Business Associate Agreement)

Start Date

Department

Office/Work Station Location

Systems Access

Check all that apply

Network Access

Network Account with Portal Access

Full Internet Access

Network Folder Access

Billing Systems

Centricity

G4

EMR Software

Email Account

Yes

No

Email

Shared Mailboxes

Wccmafax

Urfax

Surgerycenterfax

Researchfax

Radfax

Physicsdecimalscan

Operatorfax

Mrfax

marketingsupport

dermfax

hrarchive

dispensary

billingfax

acfax

acmafax

E-Mail Groups

All Staff with Physicians

All Staff without Physicians

Back Office MA’s

App Appointments

BHC/WCC Schedulers

Billing Group

Biopsy Notification

Breast Center

Breast Health Center

BreastCenterFax

CBCC Derm Providers

CBCC_All/Physicians

CbccHR

CCM

Coding Team

Confirmation Clerks

Couriers

Credentialing

CT Cover

CT-Clerks

Derm Reception Group

Dermatology

Dermatology Lab Orders

Diagnost Imaging

Exec-admin-asst

Finance

Financial Services

Fitness Team

Imaging Nurses

IMRT

Info

Insurance Verification

Intranet

Inventory

Lab Assistants

Mailtenance

Managers Group

Marketing Team

Medical Records

Midlevels

MO and RO Schedulers

MO Schedulers

Navigation

Network Access

Operators

Outside Facility Group

Pathology Staff

Paypal Foundation

ProviderNetworkAccess

Radiation Schedulers

Receptionists

Research

RO Procedure

RO Schedulers

Transcriptionists

Uclaresearch

UR Dept

Volunteer Group

WomensCenterFax

Network Folder Access

Equipment

Check all that apply

Desktop

Need New

Already Existing

NA

Laptop (contract required)

Need New

Already Existing

NA

Desk Phone:

Need New

Already Existing

NA

Ring Central Contact Name - Cellphone but no Desk Phone (If required):

Business Associate Agreement on file

Yes

No

Network Access Request Form

User Information

Systems Access

Equipment