New Hire or Staff change Request

STAFF ACCESS REQUEST

New Hire / Deactivation / Change Form

Complete the applicable sections. Fields marked are required.

Leave this field blank

Request details

New Hire Change Reactivation Deactivation On Leave Not Returning

EMR initials *

Effective date * FTE

Team member information

First name * Last name * Middle name Required for EMR Preferred name If different from above Position title * Manager name *

IT setup

Select all services that apply.

Ocean HRM eFax eSignature OLIS Transfer Email

Email address for Ocean *

CPSO or registration number *

eSignature instructions

Please email a copy of the eSignature to niharika.kumar@uppergrandfht.org .

Transfer email to *

Additional instructions Notes or actions I confirm that the information provided is accurate and authorized. *

Please do not include patient information in this form.

Accessibility Tools