Allscripts Login Security Master File

New/Change Effective Date:

MonthDayYear

Complete if a new login needs to be issued or if changes to an existing login are needed. All information is required. In the event the user is a provider and needs a schedule for Alls Vision and Alls Enterprise created, please also complete the "Alls Provider / Referring Provider Master File" and "Alls Appointment Schedule Master File".

System:

Login Status:

Request is for:

New/Change Effective Date:

MonthDayYear

Inactivation Effective Date if Applicable:

MonthDayYear

Name of User:

First NameLast Name

If user has an existing AD or MDI account please enter:

User ID to Copy:

Vision Group Code:

Vision

EHR

Role	Task Deion	Role	Task Deion	Role	Task Deion
CBO Finance	Financial reporting View only access to Financial corrections	Practice Manager/Superuser	All Functions	Provider/ APRN/ DO	Full access to orders + ERx Result verification Tasking
CBO Superuser	All Functions except Schedule template Appointment Scheduling	Front Desk	Appointment Scheduler Registration Cardscan	RN / MA	Ability to renew Meds Tasking
CBO Biller/Collector	All Functions except Schedule template Appointment Scheduling	Front Desk Plus	All Functions except Insurance follow-up Responsible Collections	Front Desk	Scheduling Delegated Tasks
CBO Clerical	Registration Financial corrections View only Cardscan	Back Office	All Functions except: Schedule template Appointment scheduling View only Cardscan	Biller	Access to change module
Provider	View Only			Fellow	Same as Provider w/ Prescribing Verification authority if they have US License

Select the appropriate Vision Role for the user from above chart:

Select the appropriate EHR Role for the user from above chart

User Details:

Vision printers user needs access to:

Vision default printer:

Vision Groups/Facilities to be linked to

Does this user roam or cover at other sites:

Payerpath Access for Claims, Remit...

Payerpath user's email:

Payerpath for Eligibility Checking?

Is the user a Collector?:

If yes enter Collection Group(s)

Policy and Procedure documents recieved

Special Instructions:

Does provider need access to EPIC?

If this is a Provider, has EPIC access been requested?

EHR INFORMATION

Providers CT License# & Expiration Date, DEA# & Expiration Date, NPI or Not Applicable:

Will Provider use a Dragon Dictaphone?:

Is the Provider an ordering Provider?:

Will this individual be using Allscript Scan Software?

Submitted By:

First NameLast Name

Date Submitted:

MonthDayYear

Phone Number:

Area CodePhone Number

Fax:

Area CodePhone Number

E-mail:

Internal Use

AD Username / Password:

Vision Username / Password:

Allscripts Username / Password:

Allscripts Scan Username / Password:

Status:

Other

Status Details:

Vision Request Completed By:

First NameLast Name

Date:

MonthDayYear

Enterprise Request Completed By:

First NameLast Name

Date:

MonthDayYear

Vendor Notified

Allscripts Login Security Master File

Vision Use Only