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Local Server User Request (Add and/or Disable Users)
Office / Practice Name
*
Client ID / Account Number (can be found on Invoice):
*
Contact Name
*
First
Last
Contact Phone
*
Contact Email
*
I would like to:
*
Add a User
Modify a User (Used to correct typos or name changes)
Remove a User
ADD USERS
You must fill in both a
FIRST
and
LAST
name when adding a new user.
Add User
*
First
Last
Type of User
*
Provider
Biller
Standard User
Do you have additional users to add?
*
Yes
No
Add User 2
First
Last
Type of User 2
*
Provider
Biller
Standard User
Do you have additional users to add?
*
Yes
No
Add User 3
*
First
Last
Type of User 3
*
Provider
Biller
Standard User
Do you have additional users to add?
*
Yes
No
Add User 4
*
First
Last
Type of User 4
*
Provider
Biller
Standard User
Do you have additional users to add?
*
Yes
No
Add User 5
*
First
Last
Type of User 5
*
Provider
Biller
Standard User
MODIFY A USER
When modifying a user, fill in both the
FIRST
and
LAST
name of the user you want to change as it is currently set, and then in the
Change User to
field, enter the corrected FIRST and LAST for that user.
Modify User:
*
First
Last
Change User to:
*
First
Last
REMOVE USERS
You must fill in both a
FIRST
and
LAST
name when removing a new user.
Remove User
*
First
Last
Do you have additional users to remove?
*
Yes
No
Remove User 2
*
First
Last
Do you have additional users to remove?
*
Yes
No
Remove User 3
*
First
Last
Do you have additional users to remove?
*
Yes
No
Remove User 4
*
First
Last
Do you have additional users to remove?
*
Yes
No
Remove User 5
*
First
Last
General Comments
Use this field to describe if new users are replacing any removed users, or for any other requests for configuration or software setups.
CLOSE
