Requester Name txtRequesterName Email txtRequesterEmail New Employee Name txtNewEmployeeName SitePrimary Location Albany CountyComal CountyCorporateEddy CountyJefferson CountyLaramie CountyLarimer CountyLuna CountyMcClennan CountyMidland CountySan Miguel CountySandoval CountyTaos CountyWashington CountyWichita County select1111 Start Date dteStartDate Office 365 SubscriptionOffice 365 Subscription Business Standard (Office + Email) - $12.50/moBusiness Basic (Email, 50GB) - $5/moKiosk (Webmail, 2GB Storage) - $2/mo cboOfficeSubscription Email Address textbox4578 Machine IDTag# of machine Office is to be installed to textbox4195 CorEMR Position Administrative AssistantAP/AR CoordinatorAssociate Regional ManagerAssistant Director of NursingBehavioral Health DirectorCase ManagerCertified Medical AssistantChief Medical OfficerClaims CoordinatorDental AssistantDentistDeputyDirector of FinanceDirector of Human ResourcesDirector of Marketing and ProposalsDirector of NursingDirector of OperationsDirector of ProposalsDirector of Risk ManagementDischarge PlannerDoctorEmergency Medical TechnicianFacility AdministratorFinance SpecialistHead NurseHealth Services AdministratorHuman Resources CoordinatorInterim Nurse SupervisorLicensed Alcohol and Drug CounselorMarketing Coordinator and CorrHealth AmbassadorMedical Administrative AssistantMedical Records ClerkMental Health ClerkMental Health CoordinatorMental Health ManagerMental Health ProfessionalNurseNurse PractitionerNurse Practitioner MedicalNurse Practitioner Psych NPOperations Training SpecialistPayroll CoordinatorPharmacy TechnicianPhysicianPhysician AssistantPsychiaristQualified Mental Health ProfessionalRe-entry SpecialistRecruiting SpecialistRegional ManagerSecretarySystem AdministratorTravel Training Team Manager cboPosition Other Additional Notes/RequestsType notes of anything not covered above. txtNotes Submit ‹›×× ×
