SWHR System Access Request Form for Specialty Offices

This request form should be completed by the primary contact in your office who will serve as the administrator to assign, change and delete user access.

Complete all fields of this form. If you have questions about system access, contact the SHWR Help Desk at help@southwesternhealth.org or 817-632-3033.

Are you the Application Account Manager?

Yes

Application account manager name

Person in the office who is responsible for user administration of SWHR applications.

First name

Last name

Application account manager email address

User information

Each user must have a unique email address. Use the plus sign (+) to the right of the text box to add users.

Action	First name	Last name	Email address	Title/role	Acuity Connect	Operations
Action	First name	Last name	Email address	Title/role	Acuity Connect

Practice/organization name

Specialty

Physical office address

Address line 1

Address line 2

City

State

ZIP code

Office phone number

Office fax number

NPI list

Enter all provider NPIs that users will need access to. Use the plus sign (+) to the right of the text box to add rows.

NPI	Provider name	Operations
NPI	Provider name

Tax ID list

Enter all organization Tax IDs and NPIs. Use the plus sign (+) to the right of the text box to add rows.

Tax ID	Organization NPI	Organization name	Operations
Tax ID	Organization NPI	Organization name

If you prefer to upload a file of NPIs and Tax IDs for your practice/group, upload your file here.

Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Today's date

Physician or office manager signature

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