SottoPelle®

Dosaggio Practice Administrator Request Form


Dosaggio Practice Administrator Request Form


Please use this request form to request assignment of your practice administrator role in our dosing application, Dosaggio.  

By completing this form, you acknowledge that you understand that assignees will have access to  the following features: 

  • Users and Roles 

  • Practice Reporting 

  • Practice Contact and Demographic Information 

  • Activity Logs 

The administrator(s) you assign will have access to future functionality assigned to this role, including financial reporting.  The practice administrator(s) you assign will have access to ePHI for your practice.  All requested administrator(s) will be required to sign a EULA prior to use of our application, if they have not already done so.  Please carefully consider your choice before proceeding. 

Provider/Practice Owner Initials:  

 

 Practice Information:


Office Name:  

Provider Name: 

Office Name:  

Phone Number:  

Email Address:  

I prefer to be contacted prior to my requested administrators being added into the application: 

Please note: If you choose not to be contacted prior to your requested administrators being added into the application, your users will be added into the application on the date our practice administrator release is completed.  Your requested administrator will receive an email from our application notifying them of their invitation to Dosaggio. 

Provider/Practice Owner Initials:  

Requested Practice Administrator(s) Information:


Please note: There is a limit of four practice administrator users per account. You are not required to list four administrators.

Name:  

Email: 

Name:  

Email:  

Name:  

Email:  

Name:  

Email:  


By signing this practice administrator request form I verify that I am authorized to make decisions regarding user access in Dosaggio for my practice.  I understand any requested administrator(s) must sign Dosaggio's EULA prior to being added into the application.  I understand that unless I specifically requested to be contacted prior to adding my requested administrator(s) to my account, the administrator will automatically be added into my Dosaggio account on the date of release. 

 

Leave this empty:

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Signature Certificate
Document name: Dosaggio Practice Administrator Request Form
lock iconUnique Document ID: b31fb170f0f9fe26fd32f267abcbcde04ffd7d03
Timestamp Audit
January 28, 2021 3:47 pm EDTDosaggio Practice Administrator Request Form Uploaded by CarolAnn Tutera - response@sphrt.com IP 107.77.196.233