System Access Request
Physicians & Office Staff
Please complete all fields marked with asterisk (*) ? Required Fields.
PART 1: Access Type

*Are you or your sponsoring Physician Credentialed with Memorial Hermann?

Yes     No
PART 2: * Access Role More Information...
*Primary Privileges
PART 3: Applicant Information
*First Name:
Middle Name/Initial:
*Last Name:
*Practice Street Address:
*Practice Name:
Office Manager:

*Office Telephone:
( ) -
Clinical Fax:
( ) -
Pager/Cell Phone:
( ) - pin#
*Date of Birth:
/ / (mm/dd/yyyy)
*Last 4 digits of social security number:
*E-mail Address:
*Confirm E-mail Address:
*Texas License #:
*MSO #:
PART 4: Sponsoring Physician Information
*Sponsoring Physician Last Name:
*Sponsoring Physician First Name:
*Sponsoring Physician E-mail Address:
*Confirm Sponsoring Physician E-mail Address:
*Sponsoring Physician Primary Facility:
*Sponsoring Physician DOB:
/ /
*MSO# / Dictation#:
*Confirm MSO# / Dictation#:
Texas License #:
Terms of Agreement (please read and sign below)
User name and password confidentiality
The purpose of your user name and password is to authenticate your identity to the computer systems. Sharing of your user name and password is prohibited by Medical Staff rules and regulations, Information Systems policies and procedures (230-1A and 2B), Memorial Hermann Hospital Medical Records Documentation Standards 2.11.4, Texas State Law and federal regulations (HIPAA). HCFA defines abuse of electronic signature: "that the physician has allowed another person or persons to use his/her personally assigned identifier".
Confidentiality of Information
All information contained in MHHS computer systems is confidential, and must not be disclosed
Examples of misuse of computer information systems:
The following list includes some examples of improper use of the privilege of using the information system:
· Accessing patient information not related to current work responsibilities
· Using another person's user name and password to gain access to any computer system
· Allowing another person to use a user name and password assigned to you
· Failing to sign off at the end of a session thus allowing another user to access data and perform actions in your account.
· Using a computer program when another user is signed on
Consequences of misuse of MHHS computer systems
· Individuals who improperly use electronic signatures or confidential information contained in a computer system will be referred to the Credentials Committee. Disciplinary action may include loss of hospital privileges.
· In the event that I misuse the electronic signature option, I understand that my use of it will be terminated.
· Legal action may be initiated by MHHS
By signing this document, I agree to the following:
· If I suspect that another person knows my password, I will immediately change my password and report the suspicion to the Support Center at 713-704-DOCS (3627).
· The use of my username and password is equivalent to my electronic signature for medical records documentation purposes.
· I understand that it is my responsibility to immediately notify MHHS at 713-704-DOCS (3627) of any staff terminations under my control so that their access to the MHHS or MH OneSource will be cancelled.
· I agree that for confidentiality and security reasons, patient medical information will not be transmitted via unsecured e-mail.
*I understand that if I do not use my OneSource username and password within 90 days that my account will be disabled and access to OneSource will cease. I will have to contact the Support Center at 713-704-DOCS (3627) to re-activate my account.
Minimum System Requirements: Windows based PC - IBM Compatible; Windows XP or better Operating System; IE 6.0 Browser ; Cable Modem, DSL or better Internet ClinicalWeb_Connection; Pentium based PC with at least 1024x768 video; Any Internet Service Provider.

Please confirm all information before submitting.