UAB Heersink SOM EHR/EMR Remote Access Request Form
  1. First Name(*)
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  2. Last Name(*)
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  3. Email Address(*)
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  4. Blazer ID(*)
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  5. Please list your Phone Type (e.g., iPhone, Android; NOT YOUR PHONE NUMBER)(*)
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  6. Please provide your cell phone number (Format: XXX.XXX.XXXX)(*)
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  7. Additional Information: Previous or Current Employment with UAB

  8. Have you been or are you currently employed by UAB ? (*)
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  9. If yes, please complete the following information:

  10. Place of Employment (e.g., Honors College, Rec Center, Chemistry, etc.)
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  11. Name of Department Contact (e.g., Mentor or Supervisor)
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  12. Are you still employed with the Department?
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  13. (*)
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