Los Angeles County, California
ADD/MODIFY/DELETE USER APPLICATION FORM
(Referral Center Staff Only)
ADD DELETE MODIFY
|USER INFORMATION | |
|Name (Last, First Middle) |Phone/Extension |
|Site (Facility) |Service Provider (Organization) |
|E-mail address |Employee Number |
|Referral Center where employee works | |
|ROLE(s) REQUESTED (please check all that apply) |
|Check (() Here|Role |
| |Appointment Assistant |
| |Referral Center Manager |
| |Referral Center Worker |
| |Reports Service Provider |
| | |
|SIGNATURES |
| | |
| | |
|User Signature Date |Requesting Supervisor Signature Date |
| | |
| | |
|Referral Center Manager Review Signature |Phone Num/Extension (Referral Center Manager) |
|Date | |
| |This certifies the above user was trained on __________ for the |
| |Referral Processing System Application. |
|Trainer Signature Date | |
|For Data Input Use Only |
|Date Received: |Date Processed: |
|Processed By: |
Go to the following link to retrieve this form: -> then select provider Information -> select Ambulatory Care -> select Web Referral -> go to the RPS Info & Resources section.
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