Software User Request
My Name
My Email Address
Are you a Practice Employee, an ARC OP CO Employee, or an ARC Health Vendor?
Please Select
Practice Employee
ARC OP CO Employee
ARC Health Vendor
Who is your primary contact at ARC Health?
Is this request for yourself or for someone you supervise?
Please Select
For Myself
For a Supervisee
Supervisor's Name
Supervisor's Email Address
User Details (For whom access is being requested)
User Email Address
Is this request for (1) creating a new user, (2) changing an existing user, OR (3) deactivating an existing user?
Creating a New User
Changing an Existing User
Deactivating an Existing User
Existing User's Login Name
Type in the Office Key(s) to turn ON
List All Keys the user should have access to
Type in the Office Key(s) to turn OFF
List Keys to be REMOVED from existing users' access
What part of AdvancedMD does the user need to access?
EHR
PM
EHR and PM
What should this user's ROLE be in AdvancedMD?
Office Manager
Front Office
Back Office
Other
Any additional notes or information?
Date of Deactivation
-
Month
-
Day
Year
Is this user also a provider/clinician?
*
Yes
No
License Type (e.g., PhD, MD, MSW)
*
License Number and State
Enter "Unlicsened" if they do not carry a license
Provider Address
*
Street Address
Street Address Line 2
City
State / Province
Zip Code + 9
Provider Phone Number
*
Provider Fax Number
*
Federal Tax ID Number
*
NPI Number
*
EPCS Required?
*
Yes
No
DEA Number
*
CLIA
Submit
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