Decrease (-) Restore Default Increase (+)
System Administrator Form

Texas Health Resources Health Information Exchange
612 E. Lamar Blvd.
Arlington, TX 76011

Clinics must establish a primary and secondary system administrator whose responsibilities include approving new access and reporting termination and role changes to ensure appropriate access. This form will only need to be filled out if your clinic is new to the HIE or a new system administrator needs to be designated. Users will not be able to obtain access until a system administrator is designated.

* Indicates required information
This Request is For * 

Clinic Name * 
Clinic Address * 
Address 2 
City * 
ZIP Code * 
Clinic Phone Number * 
Clinic Fax Number * 
Primary System Administrator * 
Phone Number * 
Email Address * 
Secondary System Administrator * 
Phone Number * 
Email Address * 
Do not include any personal health information or personal identification information not specifically requested in the form. 
Authentication * 

If the challenge words are too difficult to read, click here to refresh.