Hardware Maintenance - Change User Account Request 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 USERSYou must fill in both a FIRST and LAST name when adding a new user.Add User* First Last Type of User*ProviderBillerStandard UserDo you have additional users to add?* Yes No Add User 2 First Last Type of User 2*ProviderBillerStandard UserDo you have additional users to add?* Yes No Add User 3* First Last Type of User 3*ProviderBillerStandard UserDo you have additional users to add?* Yes No Add User 4* First Last Type of User 4*ProviderBillerStandard UserDo you have additional users to add?* Yes No Add User 5* First Last Type of User 5*ProviderBillerStandard UserMODIFY A USERWhen 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 USERSYou 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 CommentsUse this field to describe if new users are replacing any removed users, or for any other requests for configuration or software setups. Δ
