Submission: Non-Employee User Access Application

Submission: Non-Employee User Access Application
Kaweah Health maintains access for Non-Kaweah Health Employees who require a remote connection to our Electronic Medical Record (EMR) systems for purposes of treatment, payment, or healthcare operations for our mutual patients. To request access, please complete the following application in its entirety. Incomplete applications will not be considered.

Please Note:
- All Non-Employee User Access Applications will be reviewed independently to determine necessity for access to Kaweah Health’s EMR systems.
- Kaweah Health reserves the right to approve, deny, or revoke access at any time.
- You will be contacted within 3-5 business days upon submission of Non-Employee User Access Application outlining the next steps of the process. Concerns regarding the application process should be directed to the Kaweah Health Help Desk at (559) 624-2280.
Business/Provider Name
Office Manager
Office Contact Number
Please enter a valid phone number.
Business/Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Affiliation
Applicant Information

First NameLast Name
Job Title
Social Security Number
Phone Number
Please enter a valid phone number.
Business Email
Must be associated with place of employment, not a personal address.
Personal Code
Please select a 6-character code which will be used for confirming your identity. Please be sure to maintain a record of this code for future use.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a former Kaweah Health employee?

YesNo
Please list dates of employment and job title:
Have you been terminated or disciplined for a prior HIPAA violation?

YesNo
Please explain:
Do you currently have access to Kaweah Health systems?

YesNo
Please provide your username:
Please explain the reason why you are requesting access to Kaweah Health's Electronic Medical Record systems and how you will be using the information. Be specific.
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