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Remote Meditech Request Form
Staff Physicians are not required to complete this form.

First Name
Last Name
Social Security (Last 4 Digits Only)
Birth date MM/DD
Practice
Job Title
Office Phone Number
Email Address
Verify Email Address  
Terms of Agreement
Access to and use of UCH information systems carry with them specific responsibilities to our patients and the organization. To gain entry to those systems you must agree to follow the UCH policies regarding privacy, security, and protected health information. Your access and use of the system may be monitored and audited at any time. Violations of policy may result in disciplinary actions up to and including termination of employment or association with UCH, denial of future access and, as appropriate, referral for criminal prosecution.
 
                   
Disclaimer
Upper Chesapeake Health's Information Technology department is responsible for ensuring that our remote connectivity solution is available for authorized Team Members only. Due to the wide range of computer configurations, we cannot guarantee, or fully support all computer configurations. If you experience any problems with remote connectivity, please contact the Information Technology help desk at 443-843-5551 for basic support. If your issue requires advanced support, you may, at your own discretion, need to contact a local support professional.