Incident #:
Work Order #:
CTT Name:

INFORMATION TECHNOLOGY DEPARTMENT

T-SYSTEMS

All information MUST be typed or printed in all fields. Information about person for whom application is being requested:

First Name / MI: / Last Name:
User’s AD Account / Employee ID # / Extension
Entity - Cost Center / Job Code / Job Title
Department / Location
Employee Status: / /
List name and extension of BHS staff responsible for Non-BHS employee: / /
(First and Last Name)
Temp/Consulting Agency Full Name:
Contact name and number within Agency:
Duration of stay: / Start Date: / End Date:
Action: / / / Current ID: / / Current ID:
*Will user be accessing T-Systems application from a Point of Care (POC) workstation only? /
***For DOCUMENTERS Only*** Please Specify Degree or Position (i.e. MD, ARNP, RN, PA-C, ED Tech, etc.):
FLME# (if applicable): / Current PIN (if applicable): / Hospital ID (if MD, DO, PA, or ARNP)
Training Access - AG-TSystem EV Training & Test Access - AG-TSystem EV Test
Access Role (Please select one only): / Modifiers (Please select all that apply):
/ Needs PIN (Ability to lock charts)
IF NOT CHECKED-enter a 1 in the Lock PIN Field
/ Power User (Re-exports charts)
/ Hide Chief Complaint (Field will appear blank)
/ Hide Patient Name (Field will appear blank)
/ Allow Unmerge
/ Save or Email Electronic Health Information (HIM Users)
/ Save or Email Discharge Information
/ Meaningful Use Report Access
Administer Referral Doctors
Incident #:
Work Order #:
CTT Name:

Approvals: (all approval signatures must be obtained prior to returning forms to I.T.)

BHM - Adult / BMP – Urgent Care Centers
Maday Rafuls or Suzanne Balbosa-Saunders
(Fax 62512) or Donna Sparks (Fax 67995) / Jose Cruz Peraza, William Ricard, Orlando Vega, Marci Portela, Michael
BHM - / Ruckdeschel, Claudia Rodriguez, Ivelisse Bueno, Mandy Gerlach,
ED Registration / Milly Basden (Fax 67908) or Dawn Sheridan / Clarisa Suarez, or Jared Fink (Fax 63899), or Carol Simonson
(Fax 62607) / (Fax 25251), or Cristina Picado (Fax 786-662-5251), or Luis Bellmas
BHM – PEDS / (Fax 62352), or Vanna Valecillo (Fax 63801), or Michelle Lopez
Lourdes Castaneda-Jacobs or Louise / (Fax 64301), or Tanya Chang (Fax 20721), or Joe Wagner
McCarthy or Myrlene Decady-Alexis (Fax / (Fax 64201), or Elizabeth Nasser (Fax 71351), or Dr. Philip Weimer
61407), or Carol Simonson (Fax 25251) / (Fax 305-595-3088), or Jeremy Holmes (Fax 71061), or Ana M.
eICU – BHM, DH / Saperstein (Fax 71011), or Eric Schneider (Fax 786-596-3839), or
HH, MH, SMH / Beth Willmitch (Fax 33401) / Brian Graham (Fax 62394)
HH - / Lab
ED Registration / Ava Horsham (Fax 38572) or Dawn Sheridan / Eric Height (Fax 786-596-0124)
(Fax 62607) / DH -
HIM - / ED Registration / Clara Manresa (Fax 82060) or Dawn
Medical Records / Maria Alen or Kaye Heiden (Fax 46401) / Sheridan (Fax 62607)
MH - / DH
ED Registration / Dawn Sheridan (Fax 62607) / Gwen Burley (Fax 83912)
Jennifer Bell-Thomson (Fax 41661) / HH
SMH - / Sherine Craig, or Netonua Reyes
Bed Control, / Susan Butler (Fax 25041) / (Fax 38013)
Staffing Office / HIM - Coders
SMH - / Rosie Hernandez (Fax 46401)
ED Registration / Kathy Defeo (Fax 25025) or Dawn / MH
Sheridan (Fax 62607) / Dawn Stavor (Fax 41581) or
SMH - / Dawn Hire (Fax 25251)
Pharmacy / Raysa Gutierrez (Fax 25371) / RPI – BHM, DH, HH
WKBH - / MH, SMH, UC Centers / Eileen Cole (Fax 27375)
ED Registration / Anthony Carty (Fax: 786-533-9610) / SMH - ED
WKBH - ED / George Gordon, Lindsay Hindin or Tanya
Griselle Diaz or Heather Pierce / Flynn (Fax 25101) or Carol Simonson
(Fax: 786-533-9610) or / (25251)
Carol Simonson (Fax: 25251) / SMH - Imaging
IT SUPPORT / Eileen Loring (Fax 25350)
List Sites Needed / Yesenia Correa (Fax 39746)
For IT User:
Supervisor/Manager or Director/VP Name / Extension
Supervisor/Manager or Director/VP Signature / Date

Form must be returned to CTT for processing. Page 1 of 2 Ver1.5-786.533.9931-TERMMB-10.31.2013-SEC