System Access Request Form

System Access Request Form

Please complete this form for system access.

*Required field

System Access Request
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Please briefly describe this individual's role
If applicable
If applicable
Authorization Disclosure
By signing this System Access Request form, I understand that any unauthorized use or disclosure of information residing on the AxiUm and/or MiPACS clinical information systems may result in disciplinary action consistent with the policies and procedures adhered to by Creighton University.
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Select all that apply. Use ctrl/cmd + click to select multiple options.