Beth Israel Deaconess Medical Center
Request for ORBIT Access

To Be Completed by User

Last Name: _____________________________ First Name: _____________________________ Ext: __________

Department: __________________________________________________ Position: ________________________

Novell Network Login Name: _________________________________________ Server Name: ________________

Are you a BIDMC employee or physician? _________ If no, provide employer name, address and phone number:

Confidentiality of Patient Information and ORBIT Access
I am aware of and agree to abide by the following Medical Center policies regarding the confidentiality of patient information:
The unauthorized possession, use, copying, or reading of hospital records, or the disclosure of information contained in such records, or the disclosure of any unauthorized employees, is strictly forbidden. The confidential trust which law and professional ethics have imposed upon the medical and nursing profession is equally applicable to all other Medical Center employees. An employee may be terminated for failure to adhere to this policy.
Information entered or activity in ORBIT under my authorized login ID and password shall be my responsibility. I shall not:
Share my password with anyone
Leave an ORBIT PC to which I have logged on without either logging out (Windows Scheduling) or exiting to another menu screen and initiating the password function (F4) (DOS)
Use another employee's login ID or password
My login ID and password are my signature in ORBIT. Willful abuse or irregularity on my part with the above terms, shall be subject to disciplinary action.

Signature: ____________________________________________________________ Date: _____/______/______


To Be Completed by Department Director/Manager

Action: Add ___ Change: ___ Delete: ___ Start Date: ___/___/___ End Date: ___/___/___
Level of Access: (Check all that apply): Schedule ___ Journal ___ Preference List ___ Item File ___ Reports ___

Please indicate routines user will require: ____________________________________________________________


"I authorize this level of access for the above-named person. I accept responsibility for notifying the ORBIT Application Administrator when this person no longer needs this access or is on my staff."

Name (Print): _________________________________ Position: ___________________________ Ext: _________

Signature: __________________________________________________________________ Date: ____/____/____

Mail completed form to Jane Cody, ORBIT Application Administrator, FD 420A, East Campus, or fax to: 7-7058

To Be Completed by Orbit Application Administrator

ESI Group (Check one only): Nova/Titan ___ Orbit ___ Orbit/Item File ___ Nova/Preference List ___ Test System ___
Comments: ___________________________________________________________________________________
___Server Group Notified ___/___/___ ___Password Assigned ___/___/___ ____Employee Oriented ___/___/___
Signature: _______________________________________________________________ Date: ___/___/___