Create new request for practicioner or staff

Enter Requestor's Information

Note: Required fields are marked with an *

First name

Middle initial

Last name

Job title

Phone number

Ext

Company email address

Confirm company email address

For Authentication Purposes

Challenge question

Answer

Last 4 digits of your SSN

Your residence address #

Other Information

Practice/Clinic name

Authorizing person

Do you already have a Salem Health Login

Statement of Intended Use

I intend to use this access for the sole purpose of direct patient care.

I am the person requesting access pursuant to the terms of the Salem Health Confidentiality Agreement for Access to Electronic Medical Records (EMRs).

I declare the information I have provided to the Hospital in this agreement is correct and accurate.