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NEBH Network Password Request Form - CareGroup Portal

NEBH Network Password Request Form - CareGroup Portal

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125 Parker Hill Ave<br />

Boston, MA 02120<br />

Tel 617-754-5372<br />

Fax 617-754-6789<br />

New England Baptist Hospital<br />

Information Systems<br />

<strong>NEBH</strong> NETWORK PASSWORD REQUEST FORM<br />

USER INFORMATION:<br />

Last Name: First Name: Initial:<br />

Location: Phone No:<br />

Department: Supervisor Name:<br />

Employee No: Position:<br />

Are you a New England Baptist Hospital employee<br />

Yes<br />

No<br />

If yes, Full-time Part-time Temporary Contract end date:<br />

If not, please specify the reasons for this request:<br />

Please enter the company name:<br />

Address:<br />

WHAT IS BEING REQUESTED (Check all that apply):<br />

<strong>NEBH</strong> NT Domain account<br />

CITRIX MetaFrame<br />

Dialup Remote Access<br />

Others<br />

For others, please Specify:<br />

Signature:<br />

Date:<br />

Supervisor Signature:<br />

Please fill out the form above and fax or email it to HIS HELPDESK at<br />

Fax No. 617-754-6703 or nebhisreq@caregroup.harvard.edu<br />

We will contact you within 7 days to pick up your user id and password.<br />

If you have any questions, please contact our helpdesk at X45372.


125 Parker Hill Ave<br />

Boston, MA 02120<br />

Tel 617-7545372<br />

Fax 617-754670<br />

New England Baptist Hospital<br />

Information Systems<br />

USER ID<br />

PASSWORD<br />

PASSWORD SECURITY ACKNOWLEDGEMENT<br />

I understand that password is highly confidential and must not be shared with<br />

other person, except for legitimate business reasons, which have been approved<br />

by the employees' supervisor.<br />

I will take all reasonable precautions to safeguard my password. If I suspect that<br />

my password has been compromised, I will immediately change the password<br />

and report it to IS Department.<br />

The misuse of any password or misuse of information obtained by password<br />

access will be subject to disciplinary action, up to and including discharge from<br />

employment.<br />

Please sign and return it to IS Department.<br />

User Signature: _________________________<br />

Print Name: ____________________________<br />

Date:

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