External Remote Access Application

This application is to be completed by non-Virginia Mason Franciscan Health employees to apply for remote access to Virginia Mason Franciscan Health applications. It is also for you to acknowledge the Virginia Mason Franciscan Health remote access requirements/policy and verify your remote access environment.

Name:
(Legal Name or Name on License) *

Virginia Mason Franciscan Health Badge Number or Alternate Employee ID: *

Month of Birth: *

Day of Birth: *

Association with Virginia Mason Franciscan Health: *

If Other, please specify:

Will you be accessing Cerner Powerchart (EHR) remotely? *

Yes No

Job Title: *

Direct Contact Phone Number:
(Enter 10 digits without punctuation) *

Email Address: *

Confirm Email Address: *

Primary Remote Access Location: *

Virginia Mason Franciscan Health Sponsor Name: *

Virginia Mason Franciscan Health Sponsor Extension: *

I acknowledge that I will not save data in any format containing Protected Health or Proprietary Information to my workstation, unless I am using an approved, encrypted device. *

I Confirm

The workstation will not be used to email or transmit Protected Health or Virginia Mason Franciscan Health Proprietary Information to a non-Virginia Mason Franciscan Health email address. *

I Confirm

If the workstation is lost or stolen, I know to report this to Security Services. *

I Confirm

I understand that if I sell, trade or discard the workstation I will consider reasonable safeguards for destroying my hard drive. *

I Confirm

I will not allow any members of my household or our guests to use my computer while connected to Virginia Mason Franciscan Health remotely. *

I Confirm

I will secure the workstation if I must leave it unattended for any period of time. *

I Confirm

By accepting, I confirm that I have read, understand and agree to adhere to the statements above and wish to maintain remote access privileges. *

I Accept

* Required

External Remote Access Application

Requestor Information

Terms and Conditions for Remote Access