- Complete the form by filling in the required information.
- Carefully read and accept the statements of understanding.
- Click on the SUBMIT button to send the form.
- If you need assistance or have questions, please contact the SE Health FNIM Program at 1-800-463-1763 Ext. 142971. You can also email email@example.com.
This form is to be completed by the person who is requesting access to SE Health technology application, @YourSide Colleague®. Items marked with a red asterisk (*) are required.