Allscripts Enterprise VIP Status Request

Allscripts Enterprise VIP Status Request
Complete this form when requesting that a patient in your practice be identified as a VIP in the system. All VIP patients display an additional security window when anyone attempts to view the VIP’s record in the system. They are prompted to enter their password and indicate a reason for viewing the record.
Patient MRN:
Date of Birth:

MonthDayYear
If DOB is earlier the 1920 please enter DOB here:
Gender:
Please choose the option below that is appropriate (only 1 option may be chosen)
Submitted By:

First NameLast Name
Date:

MonthDayYear
Phone Number:

Area CodePhone Number
Fax:

Area CodePhone Number
E-mail:
Internal Use
Status:
Status Details:
Enterprise Completed By:

First NameLast Name
Date:

MonthDayYear
Should be Empty: