NEBH Network Password Request Form - CareGroup Portal

125 Parker Hill Ave
Boston, MA 02120
Tel 617-754-5372
Fax 617-754-6789
New England Baptist Hospital
Information Systems
NEBH NETWORK PASSWORD REQUEST FORM
USER INFORMATION:
Last Name: First Name: Initial:
Location: Phone No:
Department: Supervisor Name:
Employee No: Position:
Are you a New England Baptist Hospital employee
Yes
No
If yes, Full-time Part-time Temporary Contract end date:
If not, please specify the reasons for this request:
Please enter the company name:
Address:
WHAT IS BEING REQUESTED (Check all that apply):
NEBH NT Domain account
CITRIX MetaFrame
Dialup Remote Access
Others
For others, please Specify:
Signature:
Date:
Supervisor Signature:
Please fill out the form above and fax or email it to HIS HELPDESK at
Fax No. 617-754-6703 or nebhisreq@caregroup.harvard.edu
We will contact you within 7 days to pick up your user id and password.
If you have any questions, please contact our helpdesk at X45372.

125 Parker Hill Ave
Boston, MA 02120
Tel 617-7545372
Fax 617-754670
New England Baptist Hospital
Information Systems
USER ID
PASSWORD
PASSWORD SECURITY ACKNOWLEDGEMENT
I understand that password is highly confidential and must not be shared with
other person, except for legitimate business reasons, which have been approved
by the employees' supervisor.
I will take all reasonable precautions to safeguard my password. If I suspect that
my password has been compromised, I will immediately change the password
and report it to IS Department.
The misuse of any password or misuse of information obtained by password
access will be subject to disciplinary action, up to and including discharge from
employment.
Please sign and return it to IS Department.
User Signature: _________________________
Print Name: ____________________________
Date: