Change in Designated Employee Representative (DER) Form
Any changes to a designation or the addition of a new designation must be completed by a current DER.
Your status as a DER will be verified prior to any changes are made.
Your Name
First Name
Last Name
Your Company
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Your Email Address
example@example.com
What changes would you like to make?
Add a new DER
Remove a DER
Update a current DER's information
Update my information
NEW DER Designation
*
Will you like the new DER to have access to medical records using our online database, PureOHS?
*
Yes
No
Would you like to add another new DER?
Yes
NEW DER Designation - #2
*
Will you like this new DER to have access to medical records using our online database, PureOHS?
*
Yes
No
Would you like to add another new DER?
Yes
NEW DER Designation - #3
*
Will you like this new DER to have access to medical records using our online database, PureOHS?
*
Yes
No
Would you like to add another new DER?
Yes
NEW DER Designation - #4
*
Will you like this new DER to have access to medical records using our online database, PureOHS?
*
Yes
No
DER Removal
*
Would you like to remove another DER?
Yes
DER Removal - #2
*
Would you like to remove another DER?
Yes
DER Removal - #3
*
DER Information Update
*
Will you like this DER to have access to medical records using our online database, PureOHS?
*
Yes
No
Will you like to update another DER's information?
Yes
DER Information Update - #2
*
Will you like this DER to have access to medical records using our online database, PureOHS?
*
Yes
No
Will you like to update another DER's information?
Yes
DER Information Update - #3
*
Will you like this DER to have access to medical records using our online database, PureOHS?
*
Yes
No
You will receive a confirmation email upon submitting this form.
Submit
Should be Empty: