REQUESTING ACCESS TO: 
                                                                                      (Name of hospital or provider)

                                We currently have access to this location: yes no.

Date: 05/25/13

User Name: Phone#:

Provider Group:

Address:

Contact Person: Phone#:

FOR ACCESSING THE FOLLOWING INFORMATION:

OPERATING & MANAGEMENT SYSTEM IN MEMBERS' OFFICE:
COMPUTER OPERATING SYSTEM:
WINDOWS:    WIN 3.1 WIN 95/98
UNIX:              SCO       AIX Other - Describe:
Network?   yes no.   If yes, specify type:

OFFICE PRACTICE MANAGEMENT SYSTEM:
Medic  Medical Manager  Medisoft  Millbrook  Versus (Bradford-Scott)
Other - Please specify:

TRAINING NEEDED FOR:                         #of     Date Scheduled        Date Completed
Patient Demographics for office staff                       
Nurses Access                                                       
Physicians                                                              

OTHER SPECIFIC REQUESTS:
Please specify: