NYC Health+Hospitals Advantage Internal User Access Request Form
Title:  
First Name:  MI:  Last Name:
Suffix 1: Terminal Degree:
NYC Health+Hospitals Job Title: Facility:
Location:  
Phone 1:  Ext.:  Phone 2:  Ext.: 
Provider Emergency Phone No.:  Ext.:  Fax:
NYC Health+Hospitals Email Address: Confirm Email Address:
What kind of access are you requesting?










Please state your reason for requesting system access (300 characters max):

LDAP User Name:  
Your LDAP user name is the same user name you use to access NYC Health+Hospitals email and the Internet.

LDAP Password:
Your LDAP password is the same password you use to access NYC Health+Hospitals email and the Internet.
It is used for verification purposes only and will not be sent to the NYC Health+Hospitals Advantage system administrator.