· Access Request form for clinical applications – Inpatient, Outpatient and ED
For use by UT/UTP faculty, staff and students only.
Use a computer to complete the form. Print and sign form.
Submit to IT, by fax 419-383-3125 or email firstname.lastname@example.org
· Affiliate Access Agreement
This form is to be used if you are if you are not a UTMC, UT, UTP employee or student
This would include outside physicians, referring physicians and their office staff. Fax the entire form to 419-383-6235.
· STAR Access Request
This form is to be Printed out and completed with signature. Make sure to print your name so we can read it, then fax it to 419-383-3125
· Acknowledgement of Responsibility of Printed Medical Record
This form is to be filled after receiving training on treatment of the printed Medical Records
· Reset UTAD password
This will redirect you to the UTAD Account Management website where you can reset your password and activate existing UTAD account.