Remote Access Request

Remote Access Request

Health Information and Communications Technology

Fax: 4439-1019

Email: [email protected]

HAND-FILLED FORMS ARE NOT ACCEPTED

Requester's Information

Requester's Corp. ID: Date:
Requester's Name: Phone Number:
Requester's User ID: Section:
Department: Facility:
Dept. Director: Signature:*
Remote Access Applications: YES NO
Remote Access Local Computer ** YES NO

Disclaimer:
I _____________________ hereby agree that I have read the Remote Access Policy of HMC and fully
understood the policy. I will use the remote access for HMC business only

Requester's Signature:

* Department Director's Signature is required for non-physician applicant only.
** This privilege is strictly given to HICT staff for support purposes and other employees with similar
job nature upon approvals.

Created by: For HICT Department
Notified by:
Terminated by: Date:
HICT Authorization: Date:
Date:
Date:

HICT FORM 009 (Rev. 31/08/2014) Ref. OP-4123