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809 W Orchard Dr., Suite 7, Bellingham, WA 98225

ADD HInet User

Please complete and fax this form whenever adding staff to your office that need access to HInet resources.


Once this account has been added to the HInet system you will be notified via e-mail or phone that the account has been created. At this point the new staff member can log on to any HInet-connected computer and access select HInet core applications.

Note : If this staff member also needs access to EPIC or PeaceHealth CAG electronic medical record systems, you will need to complete seperate Peacehealth forms.


Provider Office Information

Company Name:
Site (if different):
Contact Name:
Contact Phone:


User Account to Add to HInet

Please create a user account for the following on the HInet network.  I understand that this new account will belong to the permissions group for our office.   

First Name:
Middle Initial: Always include middle initial - if no middle initial, please enter NMI.
Last Name:
Position Title:
Last 4 SSN:        Why are we asking for your SSN?
BirthDate      MM/DD/YYYY
E-mail Needed Yes   Uncheck the E-mail box if the person will not need HInet e-mail.
Alternate e-mail      Required if no Hinet e-mail.

Office Manager Authorization

Signature: ________________________

Print completed form, sign, and fax to the HInet HelpDesk at 360-671-9992

or Email to support@hinet.org

~working together for a healthier community~