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  

Crisp

UCH requires users to have CRISP access prior to requesting access to our local system.

Do you currently have access to CRISP?  

If you have not yet signed up to access your patient information via CRISP, please do so and evaluate the need to connect directly to UM UCH.

If you feel you have justification to request access to the UM UCH network please outline that requirement below so we can assess how to best assist you.


2 Factor Authentication

I am a current user with an active Upper Chesapeake account and am ready to move to 2FA. 




If yes, what is your Current UMUCH User Name?


Are you an On-staff Provider?


Justification
Please explain why you are requesting this access.
Sponsor
Name of UMUCH VP or Physician sponsoring network access
   
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.