CME PORTAL ACCESS REQUEST FORM - Clinical Informatics e-learning and in-person training

Instructions: Please complete the following request form. All requests are routed to the CME department for approval and next steps.

Baptist Heath’s Continuing Medical Education Department is responsible for maintaining the integrity and privacy of learner data and credit reporting accuracy. As terms of access for Ethos CE, our learning management, you agree to adhere to the terms delineated below and understand that the CME Department reserves the right to revoke your access.

Date *

Month

Day

Year

User Full Name *

Baptist Health AD Email Address *

Course/s Names *

List the names of the course/s you need to access.

Department *

Job Title *

Please provide the business need for access to reports within the CME LMS *

Telephone *

I agree to the following statements: *

I agree to use learner information for roster generation purposes only and will not download, save or distribute learner’s license information or personal contact information.

I agree that learner contact information will only be used for purposes of credentialing and communications about the course indicated above.

I understand that all crediting is processed solely by the Continuing Medical Education department.

I agree to notify the Continuing Medical Education department if my scope of work has changed, and I no longer need access to Ethos CE.

Inactivity in your CME account will result in deactivation.

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CME PORTAL ACCESS REQUEST FORM - Clinical Informatics e-learning and in-person training