East Alabama Health

EAMC Secure Access Request Form

Information collected may be used to set up multifactor authentication (MFA) and verify your identity when contacting EAMC for assistance.

Failure to complete all required information or electronically submitting requests will significantly delay access. Collection of this information is subject to the EAMC Privacy Policy.


Leave empty if you've never been assigned network access or don't recall.
Select facilities for physical access. Leave empty if unknown or not applicable.
Choose required software/applications. Leave empty if unknown or not applicable.

EAMC Information Security External User Security Contract

I understand that during my association with East Alabama Medical Center and its affiliates (“EAMC”), I may be granted access to certain electronic information systems. I understand I will be assigned a unique user ID and I will be responsible for setting a secure password. I understand that EAMC uses multifactor authentication to further secure access. These data points identify me to the system(s) therefore these access identifiers are considered Confidential Information. Accordingly, I will not reveal or share my access identifiers with others and if at any time I believe an identifier has been used or made known to another, I will immediately change that identifier (if authorized) or immediately contact the Help Desk (334-528-6850) and request a password. I understand any confidential information (PHI, PII, financial and other proprietary data) accessed through an EAMC computer, information system or other electronic device must be used for job-related purposes only. I understand I may not access any EAMC system (paper, electronic, or spoken) for personal reasons.

I will not make any unauthorized transmissions, copies, disclosures, inquiries, modifications, or deletions of Confidential Information. Such unauthorized transmissions include but are not limited to removing and/or transferring Confidential Information from any EAMC computer system to unauthorized locations (for instance, home). I understand that any Confidential Information accessed or viewed as a result of my access to EAMC does not belong to me.

By signing this document, you agree that you:

  • accept this document as a contract and accept responsibility for appropriate use, dissemination, and confidentiality of all information made available to you by EAMC Information Systems. This includes printouts and transfers of data to any electronic form, storage or database.
  • acknowledge that a unique EAMC Information Systems Login ID and password is assigned to you and must be kept confidential.
  • understand that your Login ID and password constitute your electronic signature. Use of your Login ID to access patient or other confidential information is equivalent to using your signature. You are accountable for all access using your Login ID.
  • will not allow any unauthorized access using your Login ID. This is regarded as a breach of confidentiality, unethical behavior and violates EAMC policy.
  • acknowledge that the system records all activities performed using your unique Login ID, and that access attributed to your Login ID will be presumed to have been performed by you.
  • understand that this access and all information provided is subject to professional confidentiality obligations and state and federal laws, including but not limited to federal HIPAA regulations regarding the access, use and confidentiality of patient records. You accept responsibility for compliance with HIPAA regulations, state laws and professional obligations, and understand that non-compliance may result in civil legal actions, state and/or federal penalties and fines.
  • agree that any indication of misuse will suspend or terminate access and could result in civil legal actions, state and/or federal penalties and fines.

EAMC IS Form 2020-1

Contract Acknowledgment and Signature

Clear Signature

We understand that your privacy and security are of the utmost importance. For your peace of mind, registration information is encrypted in-transit utilizing industry standard technologies (SSL or TLS, depending on your device support). If you are experiencing technical problems submitting this online form, please contact EAMC Technical Support at (334) 528-6850.