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User Application-Nurse Staffing
Users Facility Name:
Facility Address:
City:
State:
ZIP code:
Users First Name:
Users Last Name:
Title:
Phone Number:
Users E-mail :
Enter your business e-mail address to establish a login ID.
Choose a User Type:
Primary- One per account/Main account manager
Secondary - Backup to Primary account manager
I have read and agree
User Account and HIPAA Compliance: Users must maintain a current password to continue system access and/or system generated reports and other notifications. Passwords expire every 90 days. E-mail notifications are sent 10 days prior to an accounts deactivation. A Primary User is designated for each facility in order to manage User accounts. Primary users must contact us immediately of a User’s status change e.g. separation of employment, or duties and ensure inactive accounts are removed from our system
Replacing User:
Yes
No
Prior User unkown
If yes, please provide the prior Users information below.
Replacing First Name:
Replacing Last Name:
Effective Date:
Calendar
Today
Upload Proof of Authorization :
Instructions: Upload written authorization from the facility CEO or authorized Designate. Secondary, authorization from the COMPdata Primary Coordinator.