eCW PHC Inactivation Request Form

First
Last Name
If Jelly Beans are less than 20 --> (see note below*) Assign to:  
eRX were assigned --> Assign to:  


 

Requestor Name Phone:
Email: <- Required field fill-in

* Note: If this user has more than 20- outstanding JB's, we will reset the user's password and you may log into the user's account and re-assign them within 7- business days. At the end of the 7th business day we will inactivate the user's account.

 

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