Administrator Authorization Form

In order to update our files and to safeguard your compliance with HIPAA regulations, please complete the following form regarding security privileges within your office. Please list the person, or persons, with administration and security privileges, who are designated to set security within the ChartMaker^® Medical Suite. This form must be filled out by the licensee of the agreement with STI Computer Services, Inc.

Practice Name*
Practice Phone Number*
Authorized Licensee*
First Last Title
Authorized Licensee Email*
I authorize the following person(s) below to have permission to set security within the ChartMaker® Medical Suite.
Administration/Security User 1:
First Last Title
Administration/Security User 2:
First Last Title
Administration/Security User 3:
First Last Title

Administrator Authorization Form

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