Common Contracts
1 similar Service Provider Access Agreement contracts
Service Provider Access AgreementService Provider Access Agreement • June 16th, 2011
Service Provider Name Address Service Provider Contact Name Position Contact Office E-mail Contact Phone Number Company CEO/VP/President/Director Name Company CEO/VP/President/Director Phone Number Date access required Access termination date* (should be no later than contract termination date) Is MEDITECH Required? Yes No If yes, provide the name of a user with the same access required by this applicant (i.e. someone in a similar role) Is Remote Access required? Yes No If Yes, provide business justification and IP addresses, host names and specific network communications protocols that need to be enabled and list of applications/folders required 4 Digit Personal ID Please choose a NON sequential (not 1234 or 2222) Numeric Only Personal IDUsers must provide this number to the Service Desk before changes can be made to their account. I acknowledge, on behalf of all persons employed by our company, that all information to which they may have access to or learn about through their
