Reliance Add | Remove User Form

Add or Remove User Form

CHR & eReferrals
Directions:

Please complete this form to notify the Reliance eHealth Collaborative of user(s) who are joining or leaving the practice. Reliance staff will contact you when the change has been completed. For additional questions please email helpdesk@reliancehie.org.
Requestor Details

Change requests must be submitted by your authorized Reliance account administrator.
Practice Name*
Entity Name
Authorized by*
Enter Full Name
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Job Title*
AddRemoveAdd & Remove
- The Access to portal(s) is role based the level of access for your user(s) is determined by your selection(s). Please see details below:
  
  CHR Roles:
  
  Staff Basic - Clinic Staff will have access to only demographic information.
  
  Staff Clinical - Clinic staff will have access to clinical & demographic information.
  
  eReferral Roles:
  
  Referral Manager - Access to send/update & process inbound eReferrals. Access to referral reporting.
  
  Referral User - Full access to send/update, & process inbound eReferrals.
  
  Read Only - No editing capability.
- Should be Empty:

Requestor Details