Fillable New/Change User Request Form (Lifeways Community Mental Health)

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New/Change User Request Form (Lifeways Community Mental Health)

On average this form takes 5 minutes to complete

The New/Change User Request Form (Lifeways Community Mental Health) form is 1 page long and contains:

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  • 1 check-box
  • 19 other fields

Country of origin: US
File type: PDF

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New/Change User Request Form
New User Change User
Basic Information
First Name: MI: Last Name:
Date of Birth:
Phone
:
Hire Date:
Gender: Male Female
Email:
Termination Date:
Supervisor
:
System Information
Staff Type:
Assigned Location(s):
Credentials:
Medications Set Up
DEA Schedule: No DEA Schedule Drugs All DEA Schedule Drugs
0 plus 5 through 3 DEA Schedule
Drugs External System Information
□ This user will need a FAS System Login ID
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NewChange User Request Form (Lifeways Community Mental Health)

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Completed 5 March 2021

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